NCLEX RN Practice Test 4 with Rationale

NCLEX-RN Practice Test 4 with Rationale

Question 1.    
A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
(a) Ask the client if he has any medication allergies.
(b) Check the client’s immunization record.
(c) Apply a splint to immobilize the arm.
(d) Administer medication for pain.
Answer:
(b) Check the client’s immunization record.

Rationale:
The nurse should check the client’s immunization record to determine the date of the last tetanus immunization. The nurse should question the client regarding allergies to medications before administering medication; therefore, answer (a) is incorrect. Answer (c)  is incorrect because a sling, not a splint, should be applied to immobilize the arm and prevent dependent edema. Answer (d)  is incorrect because pain medication would be given before cleaning and dressing the wound, not afterward.

Question 2.    
The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer?    
(a) Frothy vaginal discharge
(b) Thick, white vaginal discharge
(c) Purulent vaginal discharge
(d) Watery vaginal discharge
Answer:
(d) Watery vaginal discharge

Rationale:
Watery vaginal discharge and painless bleeding are associated with endometrial cancer. Frothy vaginal discharge describes trichomonas infection; thick, white vaginal discharge describes infection with Candida albicans; and purulent vaginal discharge describes pelvic inflammatory disease. Therefore, answers (a), (b), and (c) are incorrect.

Question 3.    
A client with Parkinson’s disease is scheduled for stereotactic sur- gery. Which finding indicates that the surgery had its intended effect?
(a) The client no longer has intractable tremors.
(b) The client has sufficient production of dopamine.
(c) The client no longer requires any medication.
(d) The client will have increased production of serotonin.
Answer:
(a) The client no longer has intractable tremors.

Rationale:
Stereotactic surgery destroys areas of the brain responsible for intractable tremors. The surgery does not increase production of dopamine, making answer (b) incorrect. Answer (c) is incorrect because the client will continue to need medication. Serotonin production is not associated with Parkinson’s disease; therefore, answer (d) is incorrect.

Question 4.    
A client with AIDS asks the nurse why he cannot have a pitcher of  water left at his bedside. The nurse should tell the client that:    
(a) It would be best for him to drink ice water.
(b) He should drink several glasses of juice instead. 
(c) It makes it easier to keep a record of his intake.
(d) He should drink only freshly run water. 
Answer:
(d) He should drink only freshly run water. 

Rationale:
The client with AIDS should not drink water that has been sitting longer than 15 minutes because of bacterial contamination. Answer (a) is incorrect because ice water is not better for the client. Answer (b) is incorrect because juices should not replace water intake. Answer (c) is not an accurate statement.

Question 5.    
An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?
(a) The client is asymptomatic.
(b) The urine is free of bacteria.
(c) The urine contains blood.
(d) Males are affected more often.
Answer:
(b) The urine is free of bacteria.

Rationale:
The finding that differentiates interstitial cystitis from other forms of cystitis is the absence of bacteria in the urine. Answer (a) is incorrect because symptoms that include burning and pain on urination characterize all forms of cystitis.

Question 6.    
The mother of a male child with cystic fibrosis tells the nurse that she hopes her son’s children won’t have the disease. The nurse is aware that:
(a) There is a 25% chance that his children will have cystic fibrosis.
(b) Most of the males with cystic fibrosis are sterile.
(c) There is a 50% chance that his children will be carriers.
(d) Most males with cystic fibrosis are capable of having children, so genetic counseling is advised.
Answer:
(b) Most of the males with cystic fibrosis are sterile.

Rationale:
Approximately 99% of males with cystic fibrosis are sterile due    s to obstruction of the vas deferens. Answers (a), (c), and (d) are incorrect because most males with cystic fibrosis are incapable of reproduction.

Question 7.    
A six-month-old is hospitalized with symptoms of botulism. What aspect of the infant’s history is associated with Clostridium botu-linum infection?
(a) The infant sucks on his fingers and toes.
(b) The mother sweetens the infant’s cereal with honey.
(c) The infant was switched to soy-based formula.
(d) The father recently purchased an aquarium.
Answer:
(b) The mother sweetens the infant’s cereal with honey.

Rationale:
Infants under the age of two years should not be fed honey    because of the danger of infection with Clostridium botulinum. Answers (a), (c), and (d) are not related to the situation; therefore, they are incorrect.    

Question 8.    
The mother of a six-year-old with autistic disorder tells the nurse that her son has been much more difficult to care for since the birth of his sister. The best explanation for changes in the child’s behavior is:
(a) The child did not want a sibling,
(b) The child was not adequately prepared for the baby’s arrival.
(c) The child’s daily routine has been upset by the birth of his sister.
(d) The child is just trying to get the parent’s attention. 
Answer:
(c) The child’s daily routine has been upset by the birth of his sister.

Rationale:
Children with autistic disorder engage in ritualistic behaviors and are easily upset by changes in daily routine. Changes in the environment are usually met with behaviors that are difficult to control. Answers (a), (b), and (d) are incorrect because they do not focus on autistic disorder.

Question 9.    
The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest deter-minant of the prognosis is:
(a) The degree of pulmonary involvement 
(b) The ability to maintain an ideal weight
(c) The secretion of lipase by the pancreas
(d) The regulation of sodium and chloride excretion
Answer:
(a) The degree of pulmonary involvement 

Rationale:
The degree of pulmonary involvement is the greatest determinant in the prognosis of cystic fibrosis. Answers (b), (c), and (d) are affected by cystic fibrosis; however, they are not major determinants of the prognosis of the disease.

Question 10.    
The nurse is assessing a client hospitalized with a duodenal ulcer. Which finding should be reported to the doctor immediately?
(a) BP 82/60, pulse 120
(b) Pulse 68, respirations 24
(c) BP 110/88, pulse 56
(d) Pulse 82, respirations 16
Answer:
(a) BP 82/60, pulse 120

Rationale:
Decreased blood pressure and increased pulse rate are associated with bleeding and shock. Answers (b), (c), and (d) are within normal limits; thus, incorrect.

Question 11.    
While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should:
(a) Notify the physician immediately.
(b) Turn the client on her left side.
(c) Apply oxygen via a tight face mask.
(d) Document the finding on the flow sheet.
Answer:
(d) Document the finding on the flow sheet.

Rationale:
Early decelerations during the second stage of labor are benign and are the result of fetal head compression that occurs during normal contractions. No action is necessary other than documenting the finding on the flow sheet. Answers (a), (b), and (c) are interventions for the client with late decelerations, which reflect ureteroplacental insufficiency.

Question 12.    
The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse’s teaching?
(a) “Adding fresh ground pepper to my food will improve the flavor.”
(b) “Meat should be thoroughly cooked to the proper tem-perature.”
(c) “Eating cheese and yogurt will prevent AIDS-related diarrhea.”
(d) “It is important to eat four to five servings of fresh fruits and vegetables a day.” 
Answer:
(b) “Meat should be thoroughly cooked to the proper tem-perature.”

Rationale:
The client’s statement that meat should be thoroughly cooked to the appropriate temperature indicates an understanding of the nurse’s teaching regarding food preparation. Undercooked meat is a source of toxoplasmosis cysts. Toxoplasmosis is a major cause of encephalitis in clients with AIDS.

Answer (a) is incorrect because fresh-ground pepper contains bacteria that can cause illness in the client with AIDS. Answer (c) is an incorrect choice because cheese contains molds and yogurt contains live cultures that the client with AIDS must avoid. Answer (d) is incorrect because fresh fruit and vegetables contain microscopic organisms that can cause illness in the client with AIDS.

Question 13.    
The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid). The nurse recognizes that the client should have a negative sputum culture within:
(a) two weeks 
(b) six weeks 
(c) eight weeks 
(d) 12 weeks
Answer:
(d) 12 weeks

Rationale:
The client taking isoniazid should have a negative sputum culture within three months. Continued positive cultures reflect noncompliance with therapy or the development of strains resistant to the medication. Answers (a), (b), and (c) are incorrect because there has not been sufficient time for the medication to be effective.

Question 14.    
Which person is at greatest risk for developing Lyme’s disease?
(a) Computer programmer 
(b) Elementary teacher 
(c) Veterinarian 
(d) Landscaper
Answer:
(d) Landscaper

Rationale:
Lyme’s disease is transmitted by ticks found on deer and mice in wooded areas. The people in answers (a) and (b) have little risk of the disease. Veterinarians are exposed to dog ticks, which carry Rocky Mountain Spotted Fever, so answer (c) is incorrect.

Question 15.    
The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse’s response is based on the knowledge that sufficient sphincter control for toilet training is present by:
(a) 12-15 months of age
(b) 18-24 months of age
(c) 26-30 months of age
(d) 32-36 months of age
Answer:
(b) 18-24 months of age

Rationale:
Children ages 18-24 months normally have sufficient sphincter control necessary for toilet training. Answer (a) is incorrect because the child is not developmentally capable of toilet training. Answers (c) and (d) are incorrect choices because toilet training should already be established.

Question 16.    
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
(a) Risk for deficient fluid volume related to excessive fluid loss from ostomy
(b) Disturbed body image related to presence of ostomy
(c) Risk for impaired skin integrity related to irritation from ostomy appliance
(d) Deficient knowledge of ostomy care related to unfamil-iarity with information resources
Answer:
(a) Risk for deficient fluid volume related to excessive fluid loss from ostomy

Rationale:
The priority nursing diagnosis is risk for deficient fluid volume related to excessive fluid loss from the ostomy. The client with a new ileostomy might experience a high volume output of 1000-1800 mL per day when peristalsis returns. The client needs to increase fluid intake to 2-3 liters a day. Fluid intake should include sports drinks to help replenish sodium and potassium lost in the ileostomy output. Answers (b), (c) and (d) apply to clients with an ileostomy, but they do not take priority over the risk for deficient fluid volume; therefore, they are incorrect.

Question 17.
The physician has prescribed Cobex (cyanocobalamin) for a client following a gastric resection. Which lab result indicates that the medication is having its intended effect?
(a) Neutrophil count of 4500 cu mm
(b) Hgb of 14.2 g/dL
(c) Platelet count of 250,000 cu. mm
(d) Eeosinophil count of 200 cu mm
Answer:
(b) Hgb of 14.2 g/dL

Rationale:
Cobex is an injectable form of cyanocobalamin or vitamin B12. Increased Hgb levels reflect the effectiveness of the medication. Answers (a), (c), and (d) do not reflect the effectiveness of the medication; therefore, they are incorrect.

Question 18. 
A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?
(a) Distractors are used to interrupt repetitive or unpleasant thoughts.
(b) Techniques using stressors and exercise are used to increase awareness of body defenses.
(c) A system of tokens and rewards is used as positive reinforcement.
(d) Appropriate behavior is learned through observing the action of models.
Answer:
(c) A system of tokens and rewards is used as positive reinforcement.

Rationale:
Behavior modification relies on the principles of operant conditioning. Tokens or rewards are given for appropriate behavior. Answers (a) and (b) are incorrect because they refer to techniques used to reduce anxiety, such as thought stopping and bioenergetic techniques, respectively. Answer (d) is incorrect because it refers to modeling.

Question 19.
Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
(a) Pieces of hot dog
(b) Carrot sticks
(c) Pieces of cereal
(d) Raisins
Answer:
(c) Pieces of cereal

Rationale:
Small pieces of cereal promote chewing and are easily managed by the toddler. Pieces of hot dog, carrot sticks, and raisins are unsuitable for the toddler because of the risk of aspiration.

Question 20.    
The nurse is infusing total parenteral nutrition (TPN). The primary purpose for closely monitoring the client’s intake and output is:
(a) To determine how quickly the client is metabolizing the solution
(b) To determine whether the client’s oral intake is sufficient
(c) To detect the development of hypovolemia
(d) To decrease the risk of fluid overload
Answer:
(c) To detect the development of hypovolemia

Rationale:
Complications of TPN therapy are osmotic diuresis and hypovolemia. Answer (a) is incorrect because the intake and output would not reflect metabolic rate. Answer (b) is incorrect because the client is most likely receiving no oral fluids. Answer (d) is incorrect because the complication of TPN therapy is hypovolemia, not hypervolemia.

Question 21.    
An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?
(a) Alpha-fetoprotein
(b) Estriol level
(c) Indirect Coombs
(d) Lecithin sphingomyelin ratio
Answer:
(d) Lecithin sphingomyelin ratio

Rationale:
L/S ratios are an indicator of fetal lung maturity. Answer (a) is incorrect because it is the diagnostic test for neural tube defects. Answer (b) is incorrect because it measures fetal well-being. Answer (c) is incorrect because it detects circulating antibodies against red blood cells.

Question 22.    
Which nursing assessment indicates that involutional changes have occurred in a client who is three days postpartum?
(a) The fundus is firm and three finger widths below the umbilicus.
(b) The client has a moderate amount of lochia serosa.
(c) The fundus is firm and even with the umbilicus.
(d) The uterus is approximately the size of a small grapefruit.
Answer:
(a) The fundus is firm and three finger widths below the umbilicus.

Rationale:
By the third postpartum day, the fundus should be located three finger widths below the umbilicus. Answer (b) is incorrect because the discharge would be light in amount. Answer (c) is incorrect because the fundus is not even with the umbilicus at three days. Answer (d) is incorrect because the uterus is not enlarged.

Question 23.    
When administering total parenteral nutrition, the nurse should assess the client for signs of rebound hypoglycemia. The nurse knows that rebound hypoglycemia occurs when:
(a) The infusion rate is too rapid.
(b) The infusion is discontinued without tapering.
(c) The solution is infused through a peripheral line.
(d) The infusion is administered without a filter.
Answer:
(b) The infusion is discontinued without tapering.

Rationale:
Rapid discontinuation of TPN can result in hypoglycemia. Answer (a) is incorrect because rapid infusion of TPN results in hyperglycemia. Answer (c) is incorrect because TPN is administered through a central line. Answer (d) is incorrect because the infusion is administered with a filter.

Question 24.    
A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methys- ticum). The nurse should notify the doctor because kava-kava:
(a) Increases the effects of anesthesia and post-operative analgesia
(b) Eliminates the need for antimicrobial therapy following surgery
(c) Increases urinary output, so a urinary catheter will be needed post-operatively
(d) Depresses the immune system, so infection is more of a problem
Answer:
(a) Increases the effects of anesthesia and post-operative analgesia

Rationale:
Kava-kava can increase the effects of anesthesia and postoperative analgesia. Answers (a), (c), and (d) are not related to the use of kava-kava; therefore, they are incorrect.

Question 25.
The physician has ordered 50mEq of potassium chloride for a client with a potassium level of 2.5mEq/L. The nurse should administer the medication:
(a) Slow, continuous IV push over 10 minutes
(b) Continuous infusion over 30 minutes
(c) Controlled infusion over five hours
(d) Continuous infusion over 24 hours
Answer:
(c) Controlled infusion over five hours

Rationale:
The maximum recommended rate of an intravenous infusion of potassium chloride is 5-10mEq per hour, never to exceed 20mEq per hour. An intravenous infusion controller is always used to regulate the flow. Answer (a) is incorrect because potassium chloride is not given IV push. Answer (b) is incorrect because the infusion time is too brief. Answer (d) is incorrect because the infusion time is excessive.

Question 26.    
The nurse reviewing the lab results of a client receiving Cytoxan (cyclophasphamide) for Hodgkin’s lymphoma finds the following: WBC 4,200, RBC 3,800,000, platelets 25,000, and serum creati-nine 1 .Omg. The nurse recognizes that the greatest risk for the client at this time is:
(a) Overwhelming infection
(b) Bleeding
(c) Anemia
(d) Renal failure
Answer:
(b) Bleeding

Rationale:
The normal platelet count is 150,000-400,000; therefore, the client is at high risk for spontaneous bleeding. Answer (a) is incorrect because the WBC is a low normal; therefore, overwhelming infection is not a risk at this time. The RBC is low, but anemia at this point is not life threatening; therefore, answer (c) is incorrect. Answer (d) is incorrect because the serum creatinine is within normal limits.

Question 27.    
While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:
(a) Stop the medication from infusing
(b) Flush the IV catheter with normal saline
(c) Apply a tourniquet and call the doctor
(d) Continue the IV and assess the site for edema
Answer:
(a) Stop the medication from infusing

Rationale:
The nurse should stop the infusion. The medication should be restarted through a new IV access. Answer (b) is incorrect because IV catheters are not to be flushed. Answer (c) is incorrect because a tourniquet would not be applied to the area. Answer (d) is incorrect because the IV should not be allowed to continue infusing because the medication is a vesicant and, in the event of infiltration, the tissue would be damaged or destroyed.

Question 28.    
A client with cervical cancer has a radioactive implant. Which statement indicates that the client understands the nurse’s teach-ing regarding radioactive implants?
(a) “I won’t be able to have visitors while getting radiation therapy.”
(b) “I will have a urinary catheter while the implant is in place.”
(c) ‘‘I can be up to the bedside commode while the implant is in place.”
(d) “I won’t have any side effects from this type of therapy.” 
Answer:
(b) “I will have a urinary catheter while the implant is in place.”

Rationale:
The client will have a urinary catheter inserted to keep the bladder empty during radiation therapy. Answer (a) is incorrect because visitors are allowed to see the client for short periods of time, as long as they maintain a distance of six feet from the client. Answer (c) is incorrect because the client is on bed rest. Side effects from radiation therapy include pain, nausea, vomiting, and dehydration; therefore, answer (d) is incorrect.

 Question 29.    
 The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?    
(a) “I will apply a petroleum gauze to the area with each diaper change.”
(b) “I will clean the area carefully with each diaper change.”
(c) “I can place a heat lamp to the area to speed up the healing process.”
(d) I should carefully observe the area for signs of infec-tion.”
Answer:
(c) “I can place a heat lamp to the area to speed up the healing process.”

Rationale:
The mother does not need to place an external heat source near the newborn. It will not promote healing, and there is a chance that the newborn could be burned, so the mother needs further teaching. Answers (a), (b), and (d) indicate correct understanding of the care of the newborn who has been circumcised and therefore are incorrect choices.

Question 30.    
A client admitted for treatment of bacterial pneumonia has an order for intravenous ampicillin. Which specimen should be obtained prior to administering the medication?
(a) Routine urinalysis
(b) Complete blood count
(c) Serum electrolytes
(d) Sputum for culture and sensitivity
Answer:
(d) Sputum for culture and sensitivity

Rationale:
A sputum specimen for culture and sensitivity should be obtained before the antibiotic is administered to determine whether the organism is sensitive to the prescribed medication. A routine urinalysis, complete blood count, and serum electrolytes can be obtained after the medication is initiated; therefore, answers (a), (b), and (c) are incorrect.

Question 31.    
While obtaining information about the client’s current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
(a) Report signs of bruising or bleeding to the doctor.
(b) Avoid sun exposure while using the herbal supplement.
(c) Purchase only those brands with FDA approval.
(d) Increase daily intake of vitamin E.
Answer:
(a) Report signs of bruising or bleeding to the doctor. 

Rationale:
Ginkgo interacts with many medications to increase the risk of  bleeding; therefore, bruising or bleeding should be reported to the doctor. Photosensitivity is not a side effect of ginkgo; therefore, answer (b) is incorrect. Answer (c) is incorrect because the FDA does not regulate herbals and natural products. The client does not need to take additional vitamin E, so answer (d) is incorrect.

Question 32.    
A client with Hodgkin’s lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
(a) Slow the infusion rate.
(b) Make sure the client is well hydrated.
(c) Record the intake and output every shift.
(d) Tell the client to report ringing in the ears.
Answer:
(b) Make sure the client is well hydrated.

Rationale:
The client should be well hydrated before and during treatment to prevent nephrotoxicity. The client should be encouraged to drink 2,000-3,000mL of fluid a day to promote excretion of uric acid. Answer (a) is incorrect because it does not prevent nephrotoxicity. Answer (c) is incorrect because the intake and output should be recorded hourly. Answer (d) is incorrect because it refers to ototoxicity, which is also an adverse side effect of the medication but is not accurate for this stem.

Question 33.    
The chart of a client hospitalized for a total hip repair reveals that the client is colonized with MRSA. The nurse understands that the client:        
(a) Will not display symptoms of infection
(b) Is less likely to have an infection
(c) Can be placed in the room with others
(d) Cannot colonize others with MRSA
Answer:
(a) Will not display symptoms of infection

Rationale:
The client who is colonized with MRSA will have no symptoms associated with infection. Answer (b) is incorrect because the client is more likely to develop an infection with MRSA following invasive procedures. Answer (c) is incorrect because the client should not be placed in the room with others. Answer (d) is incorrect because the client can colonize others, including healthcare workers, with MRSA.

Question 34.    
A client receiving Vancocin (vancomycin) has a serum level of 20mcg/mL. The nurse knows that the therapeutic range for van-comycin is:
(a) 5-10mcg/mL ³ 
(b) 10-25mcg/mL ³ 
(c) 25-40mcg/mL ³ 
(d) 40-60mcg/mL 
Answer:
(b) 10-25mcg/mL ³ 

Rationale:
The therapeutic range for vancomycin is 10-25mcg/mL. Answer (a) is incorrect because the range is too low to be therapeutic. Answers (c) and (d) are incorrect because they are too high

Question 35.    
A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?
(a) Diarrhea containing blood and mucus 
(b) Cough, fever, and shortness of breath 
(c) Anorexia, weight loss, and fever 
(d) Development of ulcers on the lower extremities
Answer:
(a) Diarrhea containing blood and mucus 

Rationale:
Pseudomembranous colitis resulting from infection with Clostridium difficile produces diarrhea containing blood, mucus, and white blood cells. Answers (b), (c), and (d) are incorrect because they are not specific to infection with Clostridium difficile.

Question 36.    
Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
(a) Thiamine 
(b) Niacin 
(c) Pyridoxine 
(d) Riboflavin
Answer:
(c) Pyridoxine 

Rationale:
Pyridoxine (vitamin B6) is usually administered with INH (isoni- azid) in order to prevent nervous system side effects. Answers (a), (b), and (d) are not associated with the use of INH; therefore, they are incorrect choices.

Question 37.    
A client is admitted with suspected Legionnaires’ disease. Which factor increases the risk of developing Legionnaires’ disease?
(a) Treatment of arthritis with steroids 
(b) Foreign travel 
(c) Eating fresh shellfish twice a week 
(d) Doing volunteer work at the local hospital
Answer:
(a) Treatment of arthritis with steroids 

Rationale:
Factors associated with the development of Legionnaires’ disease include immunosuppression, advanced age, alcoholism, and pulmonary disease. Answer (b) is incorrect because it is associated with the development of SARS. Answer (c) is associated with food-borne illness, not Legionnaires’ disease, and answer (d) is not related to the question.

Question 38.    
A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
(a) Shake the inhaler and listen for the contents.
(b) Drop the inhaler in water to see if it floats.
(c) Check for a hissing sound as the inhaler is used.
(d) Press the inhaler and watch for the mist.
Answer:
(b) Drop the inhaler in water to see if it floats.

Rationale:
The client can check the inhaler by dropping it into a container of water. If the inhaler is half full, it will float upside down with one-fourth of the container remaining above the water line. Answers (a), (c), and (d) do not help determine the amount of medication remaining; therefore, they are incorrect.

Question 39.    
The nurse is caring for a client following a right nephrolithotomy. Post-operatively, the client should be positioned:
(a) On the right side
(b) Supine
(c) On the left  side
(d) Prone 
Answer:
(c) On the left side

Rationale:
Following a nephrolithotomy, the client should be positioned on the unoperative side. Answers (a), (b), and (d) are incorrect positions for the client following a nephrolithotomy.

Question 40.    
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
(a) Decreased blood pressure 
(b) Moist mucus membranes 
(c) Decreased respirations 
(d) Increased blood pressure
Answer:
(a) Decreased blood pressure 

Rationale:
The client with sickle cell crisis and sequestration can be expected to have signs of hypovolemia, including decreased blood pressure. Answer (b) is incorrect because the client would have dry mucus membranes. Answer (c) is incorrect because the client would have increased respirations because of pain associated with sickle cell crisis. Answer (d) is incorrect because the client’s blood pressure would be decreased.

Question 41.    
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
(a) Oral itching after eating bananas 
(b) Swelling of the eyes and mouth 
(c) Difficulty in breathing 
(d) Swelling and itching of the hands
Answer:
(d) Swelling and itching of the hands

Rationale:
The first sign of latex allergy is usually contact dermatitis, which includes swelling and itching of the hands. Answers (a), (b), and (c) can also occur but are not the first signs of latex allergy.

Question 42.    
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
(a) Airborne precautions will be needed.
(b) No special precautions will be needed.
(c) Contact precautions will be needed.
(d) Droplet precautions will be needed.
Answer:
(a) Airborne precautions will be needed.

Rationale:
The nurse caring for the client with disseminated herpes zoster (shingles) should use airborne precautions as outlined by the CDC. Answer (b) is incorrect because precautions are needed to prevent transmission of the disease. Answer (c) and (d) are incorrect because airborne precautions are used, not contact or droplet precautions.

Question 43.    
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
(a) Change the dressings once per shift.
(b) Moisten the dressing with sterile water.
(c) Change the dressings only when they become soiled. 
(d) Moisten the dressing with normal saline.
Answer:
(b) Moisten the dressing with sterile water.

Rationale:
Acticoat, a commercially prepared dressing, should be moistened with sterile water. Answers (a) and (c) are incorrect because Acticoat dressings remain in place up to five days. Answer (d) is incorrect because normal saline should not be used to moisten the dressing.

Question 44.    
The nurse is preparing to administer an injection to a six-month- old when she notices a white dot in the infant’s right pupil. The nurse should:
(a) Report the finding to the physician immediately.
(b) Record the finding and give the infant’s injection.
(c) Recognize that the finding is a variation of normal.
(d) Check both eyes for the presence of the red reflex. 
Answer:
(a) Report the finding to the physician immediately.

Rationale:
The presence of a white or gray dot (a cat’s eye reflex) in the pupil is associated with retinoblastoma, a highly malignant tumor of the eye. The nurse should report the finding to the physician immediately so that it can be further evaluated. Simply recording the finding can delay diagnosis and treatment; therefore, answer (b) is incorrect. Answer (c) is incorrect because it is not a variation of normal. Answer (d) is incorrect because the presence of the red reflex is a normal finding.

Question 45.    
A client is diagnosed with stage II Hodgkin’s lymphoma. The nurse recognizes that the client has involvement:
(a) In a single lymph node or single site
(b) In more than one node or single organ on the same side of the diaphragm
(c) In lymph nodes on both sides of the diaphragm
(d) In disseminated organs and tissues
Answer:
(b) In more than one node or single organ on the same side of the diaphragm

Rationale:
Stage II indicates that multiple lymph nodes or organs are involved on the same side of the diaphragm. Answer (a) refers to stage I Hodgkin’s lymphoma, answer (c) refers to stage III Hodgkin’s lymphoma, and answer (d) refers to stage IV Hodgkin’s lymphoma.

Question 46.
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
(a) Aspirin
(b) Multivitamins
(c) Omega 3 fish oils
(d) Acetaminophen
Answer:
(b) Multivitamins

Rationale:
The client taking methotrexate should avoid multivitamins because multivitamins contain folic acid. Methotrexate is a folic acid antagonist. Answers (a) and (d) are incorrect because aspirin and acetaminophen are given to relieve pain and inflammation associated with rheumatoid arthritis. Answer (c) is incorrect because omega 3 and omega 6 fish oils have proven beneficial for the client with rheumatoid arthritis.

Question 47.    
The physician has ordered a low-residue diet for a client with Crohn’s disease. Which food is not permitted in a low-residue diet?
(a) Mashed potatoes 
(b) Smooth peanut butter 
(c) Fried fish 
(d) Rice
Answer:
(c) Fried fish 

Rationale:
Fried foods are not permitted on a low-residue diet. Answers (a), (b), and (d) are all allowed on a low-residue diet and, therefore, are incorrect.

Question 48.    
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
(a) Sodium
(b) Potassium
(c) Protein
(d) Fat
Answer:
(c) Protein

Rationale:
The client with cirrhosis and abdominal ascites requires additional protein and calories. (Note: if the ammonia level increases, protein intake should be restricted or eliminated.) Answer (a) is incorrect because the client needs a low-sodium diet. Answer (b) is incorrect because the client does not need to increase his intake of potassium. Answer (d) is incorrect because the client does not need additional fat.

Question 49.    
A diagnosis of multiple sclerosis is often delayed because of the varied symptoms experienced by those affected with the disease. Which symptom is most common in those with multiple sclerosis?
(a) Resting tremors
(b) Double vision
(c) Flaccid paralysis
(d) “Pill-rolling” tremors
Answer:
(b) Double vision

Rationale:
The most common symptom reported by clients with multiple sclerosis is double vision. Answers (a), (c), and (d) are not symptoms commonly reported by clients with multiple sclerosis, so they are wrong.

Question 50.
After attending a company picnic, several clients are admitted to the emergency room with E.food poisoning. The most likely source of infection is:
(a) Hamburger
(b) Hot dog
(c) Potato salad
(d) Baked beans
Answer:
(a) Hamburger

Rationale:
Common sources of E. coli are undercooked beef and shellfish. Answers (b), (c), and (d) are incorrect because they are not sources of E. coli.

Question 51.    
A client tells the nurse that she takes St. John’s wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
(a) St. John's wort seldom relieves depression.
(b) She should avoid eating aged cheese.
(c) Skin reactions increase with the use of sunscreen.
(d) The herbal is safe to use with other antidepressants.
Answer:
(b) She should avoid eating aged cheese.

Rationale:
St. John’s wort has properties similar to those of monoamine oxidase inhibitors (MAOI). Eating foods high in tryramine (example: aged cheese, chocolate, salami, liver) can result in a hypertensive crisis. Answer (a) is incorrect because it can relieve mild to moderate depression. Answer (c) is incorrect because use of a sunscreen prevents skin reactions to sun exposure. Answer (d) is incorrect because St. John's wort should not be used with MAOI antidepressants.

Question 52.    
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
(a) Dried beans
(b) Nuts
(c) Cheese
(d) Eggs
Answer:
(a) Dried beans

Rationale:
Foods high in purine include dried beans, peas, spinach, oat meal, poultry, fish, liver, lobster, and oysters. Answers (b), (c), and (d) are incorrect because they are low in purine. Other sources low in purine include most vegetables, milk, and gelatin.

Question 53.    
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
(a) Two finger widths are noted between the axilla and the top of the crutch.
(b) The client bears weight on his hands when ambulating.
(c) The crutches and the client’s feet move alternately.
(d) The client bears weight on his axilla when standing.
Answer:
(d) The client bears weight on his axilla when standing.

Rationale:
The nurse should tell the client to avoid bearing weight on the axilla when using crutches because it can result in nerve damage. Answer (a) is incorrect because the finger width between the axilla and the crutch is appropriate. Answer (b) is incorrect because the client should bear weight on his hands when ambulating with crutches. Answer (c) is incorrect because it describes the correct use of the four-point gait.

Question 54.    
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client’s daughter. The nurse could be sued for:
(a) Libel
(b) Slander
(c) Malpractice
(d) Negligence
Answer:
(a) Libel

Rationale:
By writing down her suspicions, the nurse leaves herself open for a suit of libel, a defamatory tort that discloses a privileged communication and leads to a lowering of opinion of the client. Defamatory torts include libel and slander. Libel is a written statement, whereas slander is an oral statement. Thus, answer (b) is incorrect because it involves oral statements. Malpractice is an unreasonable lack of skill in performing professional duties that result in injury or death; therefore, answer (c) is incorrect. Negligence is an act of omission or commission that results in injury to a person or property, making answer (d) incorrect.

Question 55.    
The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
(a) Extreme weight    loss
(b) Dental caries
(c) Hair loss
(d) Decreased temperature
Answer:
(b) Dental caries

Rationale:
The client with bulimia is prone to tooth erosion and dental caries caused by frequent bouts of self-induced vomiting. Answers (a), (c), and (d) are findings associated with anorexia nervosa, not bulimia, and are incorrect.

Question 56.    
A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25mg daily. Which of the following statements indicates that the client needs further teaching?
(a) “I will need to take the medication at the same time each day.”
(b) “I can prevent stomach upset by taking the medication with an antacid.”
(c) “I can help prevent drug toxicity by eating foods containing fiber.”
(d) “I will need to report visual changes to my doctor.”
Answer:
(b) “I can prevent stomach upset by taking the medication with an antacid.”

Rationale:
Antacids should not be taken within two hours of taking digoxin; therefore, the nurse needs to do additional teaching regarding the client’s medication. Answers (a), (c), and (d) are true statements indicating that the client understands the nurse’s teaching, so they are incorrect.

Question 57.    
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
(a) Fever, sore throat, weakness 
(b) Dry mouth, constipation, blurred vision 
(c) Lethargy, slurred speech, thirst
(d) Fatigue, drowsiness, photosensitivity
Answer:
(a) Fever, sore throat, weakness 

Rationale:
Fever, sore throat, and weakness need to be reported immediately. Adverse reactions to Thorazine include agranulocytosis, which makes the client vulnerable to overwhelming infection. Answers (b), (c), and (d) are expected side effects that occur with the use of Thorazine; therefore, it is not necessary to notify the doctor immediately.

Question 58.    
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
(a) Drainage on the surgical dressing 
(b) Complaints of neck pain 
(c) Bleeding from the mouth 
(d) Swelling in the posterior neck 
Answer:
(c) Bleeding from the mouth 

Rationale:
The anterior approach for cervical discectomy lends itself to covert bleeding. The nurse should pay particular attention to bleeding coming from the mouth. Answer (a) is incorrect because bleeding will be obvious on the surgical dressing. Answer (b) is incorrect because complaints of neck pain are expected and will be managed by the use of analgesics. Answer (d) is incorrect because swelling in the posterior neck can be expected. The nurse should observe for swelling in the anterior neck as well as changes in voice quality, which can indicate swelling of the airway.

Question 59.    
The initial assessment of a newborn reveals a chest circumference of 34cm and an abdominal circumference of 31cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
(a) Providing supplemental oxygen by a ventilated mask
(b) Performing auscultation of the abdomen for the presence of active bowel sounds
(c) Inserting a nasogastric tube to check for esophageal patency
(d) Positioning on the left side with head and chest elevated
Answer:
(d) Positioning on the left side with head and chest elevated

Rationale:
The assessment suggests the presence of a diaphragmatic hernia. The newborn should be positioned on the left side with the head and chest elevated. This position will allow the lung on the right side to fully inflate. Supplemental oxygen for newborns is not provided by mask, therefore answer (a) is incorrect. Answer (b) is incorrect because bowel sounds would not be heard in the abdomen since abdominal contents occupy the chest cavity in the newborn with diaphragmatic hernia. Inserting a nasogastric tube to check for esophageal patency refers to the newborn with esophageal atresia; therefore, answer (c) is incorrect.

Question 60.    
The physician has ordered Eskalith (lithium carbonate) 500mg three times a day and Risperdal (risperidone) 2mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client’s medication regimen is:
(a) The client’s symptoms of acute mania are typical of undiagnosed schizophrenia.
(b) Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
(c) The client will be more compliant with a medication that allows some feelings of hypomania.
(d) Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Answer:
(b) Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.

Rationale:
It takes 1-2 weeks for mood stabilizers to achieve a therapeutic effect; therefore, antipsychotic medications can also be used during the first few days or weeks to manage behavioral excitement. Answers (a) and (d) are not true statements and, therefore, are incorrect. Answer (c) is incorrect because the combination of medications will not allow for hypomania.

Question 61.    
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
(a) Ignore the client’s behavior.
(b) Exchange the cards for a checker board.
(c) Send the other clients to their rooms.
(d) Cover the client and walk her to her room.
Answer:
(d) Cover the client and walk her to her room.

Rationale:
The nurse should first provide for the client’s safety, including protecting her from an embarrassing situation. Answer (a) is incorrect because it allows the client to continue unacceptable behavior. Answer (b) is incorrect because it does not stop the client’s behavior. Answer (c) is incorrect because it focuses on the other clients, not the client with inappropriate behavior.

Question 62.    
A child with Down syndrome has a developmental age of four years. According to the Denver Developmental Assessment, the four-year-old should be able to:
(a) Draw a man in six parts
(b) Give his first and last name
(c) Dress without supervision
(d) Define a list of words 
Answer:
(b) Give his first and last name

Rationale:
According to the Denver Developmental Assessment, a four-year-old should be able to state his first and last name. Answers (a) and (c) are expected abilities of a five-year-old, and answer (d) is an expected ability of a five-and six-year-old.

Question 63.    
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client’s mother states, “Sometimes she is more than we can manage.” Based on the mother’s statement, the most appropriate nursing diagnosis is:
(a) Ineffective family coping related to parental role conflict
(b) Care-giver role strain related to chronic situational stress
(c) Altered family process related to impaired social interaction
(d) Altered parenting related to impaired growth and development
Answer:
(b) Care-giver role strain related to chronic situational stress

Rationale:
The mother’s statement reflects the stress placed on her by her daughter’s chronic mental illness. Answer (a) is incorrect because there is no indication of ineffective family coping. Answer (c) is incorrect because it is not the most appropriate nursing diagnosis. Answer (d) is incorrect because there is no indication of altered parenting.

Question 64.    
An adolescent client hospitalized with anorexia nervosa is described by her parents as “the perfect child.” When planning care for the client, the nurse should:
(a) Allow her to choose what foods she will eat
(b) Provide activities to foster her self-identity
(c) Encourage her to participate in morning exercise
(d) Provide a private room near the nurse’s station
Answer:
(b) Provide activities to foster her self-identity

Rationale:
Clients with anorexia nervosa have problems with developing self-identity. They are often described by others as “passive,” “perfect,” and “introverted.” Poor self-identity and low self-esteem lead to feelings of personal ineffectiveness. Answer (a) is incorrect because she will choose only low-calorie food items.

Answer (c) is incorrect because the client with anorexia is restricted from exercising because it promotes weight loss. Placement in a private room increases the likelihood that the client will continue activities that prevent weight gain; therefore, answer (d) is incorrect.

Question 65.    
The nurse is assigning staff to care for a number of clients with emotional disorders. Which facet of care is suitable to the skills of the nursing assistant?
(a) Obtaining the vital signs of a client admitted for alcohol withdrawal
(b) Helping a client with depression with bathing and grooming
(c) Monitoring a client who is receiving electroconvulsive therapy
(d) Sitting with a client with mania who is in seclusion
Answer:
(b) Helping a client with depression with bathing and grooming

Rationale:
The nursing assistant has skills suited to assisting the client with activities of daily living, such as bathing and grooming. Answer (a) is incorrect because the nurse should monitor the client’s vital signs. Answer (c) is incorrect because the client will have an induced generalized seizure, and the nurse should monitor the client’s response before, during, and after the procedure. Answer (d) is incorrect because staff does not remain in the room with a client in seclusion; only the nurse should monitor clients who are in seclusion.

Question 66.    
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
(a) Shave the area before applying the patch
(b) Remove the old patch and clean the skin with alcohol
(c) Cover the patch with plastic wrap and tape it in place
(d) Avoid cutting the patch because it will alter the dose 
Answer:
(d) Avoid cutting the patch because it will alter the dose 

Rationale:
Transderm Nitro is a reservoir patch that releases the medication via a semipermeable membrane. Cutting the patch allows too much of the drug to be released. Answer (a) is incorrect because the area should not be shaved; this can cause skin irritation. Answer (b) is incorrect because the skin is cleaned with soap and water. Answer (c) is incorrect because the patch should not be covered with plastic wrap because it can cause the medication to absorb too rapidly.

Question 67.    
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
(a) Decreased blood pressure and constricted pupils 
(b) Increased heart rate and increased respirations 
(c) Increased respirations and increased blood pressure 
(d) Anoxia and absence of the cough reflex
Answer:
(a) Decreased blood pressure and constricted pupils 

Rationale:
Cholinergic crisis is the result of overmedication with anticholinesterase inhibitors. Symptoms of cholinergic crisis are nausea, vomiting, diarrhea, blurred vision, pallor, decreased blood pressure, and constricted pupils. Answers (b), (C), and (d) are incorrect because they are symptoms of myasthenia crisis, which is the result of undermedication with cholinesterase inhibitors.

Question 68.    
The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium- restricted diet?
(a) Dried beans
(b) Swiss cheese
(c) Peanut butter
(d) Colby cheese
Answer:
(d) Colby cheese

Rationale:
The client should avoid eating American and processed cheeses, such as Colby and Cheddar, because they are high in sodium. Dried beans, peanut butter, and Swiss cheese are low in sodium; therefore, answers (a), (b), and (c) are incorrect.

Question 69.    
A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
(a) 20%
(b) 35%
(c) 45%
(d) 60%
Answer:
(c) 45%

Rationale:
According to the Rule of Nines, the arm (9%) + the trunk (36%)
= 45% TBSA burn injury. Answers (a), (b), and (d) are inaccurate calculations for the TBSA.

Question 70.    
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
(a) Provide the client with a urinal
(b) Prep the area by shaving the abdomen 
(c) Encourage the client to drink extra fluids 
(d) Request an ultrasound of the abdomen
Answer:
(a) Provide the client with a urinal

Rationale:
The client should void before the paracentesis to prevent accidental trauma to the bladder. Answer (b) is incorrect because the abdomen is not shaved. Answer (c) is incorrect because the client does not need extra fluids, which would cause bladder distention. Answer (d) is incorrect because the physician, not the nurse, would request an ultrasound, if needed.

Question 71.    
Which of the following combinations of foods is appropriate for an eight-month-old infant?
(a) Cocoa-flavored cereal, orange juice, and strained meat 
(b) Graham crackers, strained prunes, and pudding 
(c) Rice cereal, bananas, and strained carrots 
(d) Mashed potatoes, strained beets, and whole milk 
Answer:
(c) Rice cereal, bananas, and strained carrots 

Rationale:
Rice cereal, mashed ripe bananas, and strained carrots are appropriate foods for an eight-month-old infant. Answer (a) is incorrect because the cocoa-flavored cereal contains chocolate and sugar, orange juice is too acidic for the infant, and strained meat is difficult to digest. Answer (b) is incorrect because graham crackers contain wheat flour and sugar. Pudding contains sugar and additives unsuit¬able for the eight-month-old. Answer (d) is incorrect because whole milk should not be given before the age of one year..

Question 72.    
The mother of a nine-year-old with asthma has brought an electric CD player for her son to listen to while he is receiving oxygen therapy. The nurse should:
(a) Explain that he does not need the added stimulation.
(b) Allow the player, but ask him to wear earphones.
(c) Tell the mother that he cannot have items from home.
(d) Ask the mother to bring a battery-operated CD instead.
Answer:
(d) Ask the mother to bring a battery-operated CD instead.

Rationale:
A battery-operated CD player is a suitable diversion for the nine-year-old who is receiving oxygen therapy for asthma. He should not have an electric player while receiving oxygen therapy because of the danger of fire. Answer (a) is incorrect because he does need diversional activity. Answer (b) is incorrect because there is no need for him to wear earphones while he listening to music. Answer (c) is incorrect because he can have items from home.

Question 73.    
Which one of the following situations represents a maturational crisis for the family?
(a) A four-year-old entering nursery school 
(b) Development of preeclampsia during pregnancy 
(c) Loss of employment and health benefits 
(d) Hospitalization of a grandfather with a stroke
Answer:
(a) A four-year-old entering nursery school 

Rationale:
Maturational crises are normal expected changes that face the family. Entering nursery school is a maturational crisis because the child begins to move away from the family and spend more time in the care of others. It is a time of adjustment for both the child and the parents. Answers (b), (c), and (d) are incorrect because they represent situational crises.

Question 74.    
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client’s intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
(a) An affected gene is located on one of the 21 pairs of autosomes.
(b) The disorder is caused by an over-replication of the X chromosome in males.
(c) The affected gene is located on the Y chromosome of the father.
(d) The affected gene is located on the X chromosome of the mother. 
Answer:
(a) An affected gene is located on one of the 21 pairs of autosomes.

Rationale:
The client with a history of phenylketonuria should not use Nutrasweet or other sugar substitutes containing aspartame because aspartame is not adequately metabolized by the client with PKU. Answers (b) and (c) indicate an understanding of the nurse’s teaching; therefore, they are incorrect. The client needs to resume a low-phenylalanine diet, making answer (d) incorrect.

Question 75.
Parents of a toddler are dismayed when they learn that their child has Duchenne's muscular dystrophy. Which statement describes the inheritance pattern of the disorder?
shorten the duration of fever and itching?
(a) Zovirax (acyclovir)
(b) Varivax (varicella vaccine)
(c) VZIG (varicella-zoster immune globulin)
(d) Periactin (cyproheptadine)
Answer:
(d) Periactin (cyproheptadine)

Rationale:
Duchenne’s muscular dystrophy is a sex-linked disorder, with the affected gene located on the X chromosome of the mother. Answer (a) is incorrect because the affected gene is not located on the autosomes. Over-replication of the X chromosomes in males is known as Klinefelter’s syndrome; therefore, answer (b) is incorrect. Answer (c) is incorrect because the disorder is not located on the Y chromosome of the father.

Question 76.    
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
(a) Helping the client develop a plan for changing his behavior
(b) Contracting with him for the time he spends on a task
(c) Avoiding a discussion of his annoying behavior because it will only make him worse
(d) Encouraging him to set a time schedule and deadlines for himself
Answer:
(b) Contracting with him for the time he spends on a task

Rationale:
The nurse and the client should work together to form a contract that outlines the amount of time he spends on a task. Answer (a) is incorrect because the client with a personality disorder will see no reason to change. The nurse should discuss his behavior and its effects on others with him, so answer (c) is incorrect. Answer (d) is incorrect because the client will not be able to set schedules and dead lines for himself.

Question 77.    
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which med-ication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
(a) Zovirax (acyclovir)
(b) Varivax (varicella vaccine)
(c) VZIG (varicella-zoster immune globulin)
(d) Periactin (cyproheptadine)
Answer:
(a) Zovirax (acyclovir)

Rationale:
Zovirax (acyclovir) shortens the course of chickenpox; however, the American Academy of Pediatrics does not recommend it for healthy children because of the cost. Answer (b) is incorrect because it is the vaccine used to prevent chickenpox. Answer (c) is incorrect because it is the immune globulin given to those who have been exposed to chickenpox. Answer (d) is incorrect because it is an antihistamine used to control itching associated with chickenpox.

Question 78.    
One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
(a) An 18-month-old with sock and mitten burns from a fall into the bathtub
(b) A six-year-old with a fractured clavicle following a fall from her bike
(c) An eight-year-old with a concussion from a skateboarding accident
(d) A two-year-old with burns to the scalp and face from a grease spill
Answer:
(a) An 18-month-old with sock and mitten burns from a fall into the bathtub

Rationale:
Sock and mitten burns, burns confined to the hands and feet, indicate submersion in a hot liquid. Falling into the tub would not have produced sock burns; therefore, the nurse should be alert to the possibility of abuse. Answer (b) and (c) are within the realm of possibility, given the active play of the school-aged child; there¬fore, they are incorrect. Answer (d) is within the realm of possibility; therefore, it is incorrect.

Question 79.    
A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse’s comments can result in a charge of:
(a) Malpractice
(b) Assault
(c) Negligence
(d) Battery 
Answer:
(b) Assault

Rationale:
Assault is the intentional threat to bring about harmful or offensive contact. The nurse’s threat to give the medication by injection can be considered as assault. Answers (a), (c), and (d) do not relate to the nurse’s statement; therefore, they are incorrect.

Question 80.    
During morning assessments, the nurse finds that a client’s nephrostomy tube has been clamped. The nurse’s first action should be to:
(a) Assess the drainage bag.
(b) Check for bladder distention.
(c) Unclamp the tubing.
(d) Irrigate the tubing.
Answer:
(c) Unclamp the tubing.

Rationale:
A nephrostomy tube is placed directly into the kidney and should not be clamped or irrigated because of the damage that can result to the kidney. Answers (a) and (b) are incorrect because the first action should be to relieve pressure on the affected kidney. Answer (d) is incorrect because the tubing should not be irrigated.

Question 81.    
The nurse caring for a client with chest tubes notes that the Pleuravac’s collection chambers are full. The nurse should:
(a) Add more water to the suction-control chamber.
(b) Remove the drainage using a 60mL syringe.
(c) Milk the tubing to facilitate drainage.
(d) Prepare a new unit for continuing collection.
Answer:
(d) Prepare a new unit for continuing collection.

Rationale:
When the collection chambers of the Pleuravac are full, the nurse should prepare a new unit for continuing the collection. Answer (a) is incorrect because the unit is providing suction, so the amount of water does not need to be increased. Answer (b) is incorrect because the drainage is not to be removed using a syringe. Milking a chest tube requires a doctor’s order, and because the tube is draining in this case, there is no need to milk it, so answer (c) is incorrect.

Question 82.    
A client with severe anemia is to receive a unit of packed red blood cells. In the event of a transfusion reaction, the first action by the nurse should be to:
(a) Notify the physician and the nursing supervisor.
(b) Stop the transfusion and maintain an IV of normal saline.
(c) Call the lab for verification of type and cross match.
(d) Prepare an injection of Benadryl (diphenhydramine).
Answer:
(b) Stop the transfusion and maintain an IV of normal saline.

Rationale:
The first action by the nurse is to stop the transfusion and maintain an IV of normal saline. Answers (a), (c), and (d) are incorrect because they are not the first action the nurse would take.

Question 83.    
A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby’s feedings. The nurse should:
(a) Explain that a microwave should never be used to warm the baby’s bottles.
(b) Tell the mother that microwaving is the best way to prevent bacteria in the formula.
(c) Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.
(d) Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape. 
Answer:
(a) Explain that a microwave should never be used to warm the baby’s bottles.

Rationale:
Microwaving can cause uneven heating and “hot spots” in the formula, which can cause burns to the baby’s mouth and throat. Answers (b), (c), and (d) are incorrect because the infant’s formula should never be prepared using a microwave.

Question 84.
A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:    
(a) Serum glucose levels
(b) Liver enzymes
(c) Pancreatic enzymes
(d) Plasma protein levels
Answer:
(b) Liver enzymes

Rationale:
HELLP syndrome is characterized by hemolytic anemia, elevated liver enzymes, and low platelet counts. Answers (a), (c), and (d) have no connection to HELLP syndrome, so they are incorrect.

Question 85.    
To reduce the possibility of having a baby with a neural tube defect, the client should be told to increase her intake of folic acid. Dietary sources of folic acid include:
(a) Meat, liver, eggs
(b) Pork, fish, chicken
(c) Spinach, beets, cantaloupe
(d) Dried beans, sweet potatoes, Brussels sprouts
Answer:
(c) Spinach, beets, cantaloupe

Rationale:
Dark green, leafy vegetables; members of the cabbage family; beets; kidney beans; cantaloupe; and oranges are good sources of folic acid (B9). Answers (a), (b), and (d) are incorrect because they are not sources of folic acid. Meat, liver, eggs, dried beans, sweet potatoes, and Brussels sprouts are good sources of B12; pork, fish, and chicken are good sources of B6.

Question 86.    
The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
(a) A multigravida with diabetes mellitus
(b) A primigravida with preeclampsia
(c) A multigravida with preterm    labor
(d) A primigravida with hyperemesis gravidarum
Answer:
(b) A primigravida with preeclampsia

Rationale:
The client with preeclampsia should be kept as quiet as possible, to minimize the possibility of seizures. The client should be kept in a dimly lit room with little or no stimulation. The clients in answers (a), (c), and (d) do not require a private room; therefore, they are incorrect.

Question 87.    
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
(a) Loss of the myelin sheath in portions of the brain and spinal cord
(b) An interruption in the transmission of impulses from nerve endings to muscles
(c) Progressive weakness and loss of sensation that begins in the lower extremities
(d) Loss of coordination and stiff “cogwheel” rigidity
Answer:
(b) An interruption in the transmission of impulses from nerve endings to muscles

Rationale:
Myasthenia gravis is caused by a loss of acetylcholine receptors, which results in the interruption of the transmission of nerve impulses from nerve endings to muscles. Answer (a) is incorrect because it refers to multiple sclerosis. Answer (c) is incorrect because it refers to Guillain-Barre syndrome. Answer (d) is incorrect because it refers to Parkinson’s disease

Question 88.
The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?
(a) Increased pulse rate
(b) Increased urinary output
(c) Decreased diastolic blood pressure
(d) Increased pupil size
Answer:
(b) Increased urinary output

Rationale:
Osmitrol (mannitol) is an osmotic diuretic, which inhibits reabsorption of sodium and water. The first indication of its effectiveness is an increased urinary output. Answers (a), (c), and (d) do not relate to the effectiveness of the drug, so they are incorrect.

Question 89.    
The nurse has just received the change of shift report. Which client should the nurse assess first?
(a) A client with a supratentorial tumor awaiting surgery 
(b) A client admitted with a suspected subdural hematoma 
(c) A client recently diagnosed with akinetic seizures 
(d) A client transferring to the neuro rehabilitation unit
Answer:
(b) A client admitted with a suspected subdural hematoma 

Rationale:
The client with a suspected subdural hematoma is more critical than the other clients and should be assessed first. Answers (a), (c), and (d) have more stable conditions; therefore, they are incorrect.

Question 90.    
The physician has ordered an IV bolus of Solu-Medrol (methyl- prednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
(a) Preventing spasticity associated with cord injury 
(b) Decreasing the need for mechanical ventilation 
(c) Improving motor and sensory functioning 
(d) Treating post injury urinary tract infections
Answer:
(c) Improving motor and sensory functioning 

Rationale:
When given within eight hours of the injury, Solu-Medrol has proven effective in reducing cord swelling, thereby improving motor and sensory function. Answer (a) is incorrect because Solu-Medrol does not prevent spasticity. Answer (b) is incorrect because Solu-Medrol does not decrease the need for mechanical ventilation. Answer (d) is incorrect because Solu-Medrol is used to reduce inflammation, not used to treat infections.

Question 91.    
The physician has ordered a lumbar puncture for a client with sus-pected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
(a) Decreased protein concentration with a normal cell count
(b) Increased protein concentration with a normal cell count
(c) Increased protein concentration with an abnormal cell count
(d) Decreased protein concentration with an abnormal cell count
Answer:
(b) Increased protein concentration with a normal cell count

Rationale:
The spinal fluid of a client with Guillain-Barre has an increased protein concentration with normal or near-normal cell counts. Answers (a), (c), and (d) are inaccurate statements; therefore, they are incorrect.

Question 92.    
An 18-month-old is admitted to the hospital with acute laryngotra-cheobronchitis. When assessing the respiratory status, the nurse should expect to find:
(a) Inspiratory stridor and harsh cough 
(b) Strident cough and drooling 
(c) Wheezing and intercostal retractions 
(d) Expiratory wheezing and nonproductive cough 
Answer:
(a) Inspiratory stridor and harsh cough 

Rationale:
The child with laryngotracheobronchitis has inspiratory stridor and a harsh, “brassy” cough. Answer (b) refers to the child with epiglotttis, answer (c) refers to the child with bronchiolitis, and answer (d) refers to the child with asthma.

Question 93.    
The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?
(a) Pain, coolness, and blue discoloration in the affected joint
(b) Tingling and pain without loss of movement in the affected joint
(c) Warmth, redness, and decreased movement in the affected joint
(d) Stiffness, aching, and decreased movement in the affected joint
Answer:
(d) Stiffness, aching, and decreased movement in the affected joint

Rationale:
Hemarthrosis or bleeding into the joints is characterized by stiffness, aching, tingling, and decreased movement in the affected joint. Answers (a), (b), and (c) do not describe hemarthrosis, so they are incorrect.

Question 94.    
The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
(a) Decrease respiratory effort and mucous production 
(b) Increase efficiency of the diaphragm and gas exchange 
(c) Dilate the bronchioles and help remove secretions 
(d) Stimulate coughing and oxygen consumption
Answer:
(c) Dilate the bronchioles and help remove secretions 

Rationale:
The objective of therapy using aerosol treatments and chest percussion and postural drainage is to dilate the bronchioles and help loosen secretions. Answers (a), (b), and (d) are inaccurate statements, so they are incorrect.

Question 95.    
The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?
(a) Drooling of bright red secretions 
(b) Pulse rate of 90 
(c) Vomiting of dark brown liquid 
(d) Infrequent swallowing while sleeping
Answer:
(a) Drooling of bright red secretions 

Rationale:
Drooling of bright red secretions indicates active bleeding. Answer (b) is incorrect because the heart rate is within normal range for a six-year-old. Answer (c) is incorrect because it indicates old bleeding. Answer (d) is incorrect because the child would have frequent, not infrequent, swallowing.

Question 96.    
A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client’s diagnosis?
(a) Smoking a pack of cigarettes a day for 30 years 
(b) Use of nonsteroidal anti-inflammatories 
(c) Eating foods with preservatives 
(d) Past employment involving asbestos 
Answer:
(a) Smoking a pack of cigarettes a day for 30 years 

Rationale:
Cigarette smoking is the number one cause of bladder cancer. Answer (b) is incorrect because it is not associated with bladder cancer. Answer (c) is a primary cause of gastric cancer, and answer (d) is a cause of certain types of lung cancer.

Question 97.    
The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
(a) The dialysate returns become cloudy in appearance.
(b) The return of the dialysate is slower than usual.
(c) A “tugging” sensation is noted as the dialysate drains.
(d) A feeling of fullness is felt when the dialysate is instilled.
Answer:
(a) The dialysate returns become cloudy in appearance.

Rationale:
Cloudy or whitish dialysate returns should be reported to the doctor immediately because it indicates infection and impending peritonitis. Answers (b), (c), and (d) are expected with peritoneal dialysis and do not require the doctor’s attention.

Question 98.    
The physician has prescribed nitroglycerin sublingual tablets as needed for a client with angina. The nurse should tell the client to take the medication:
(a) After engaging in strenuous activity
(b) Every four hours to prevent chest pain
(c) As soon as he notices signs of chest pain
(d) At bedtime to prevent nocturnal angina
Answer:
(c) As soon as he notices signs of chest pain

Rationale:
Nitroglycerin tablets should be used as soon as the client first notices chest pain or discomfort. Answer (a) is incorrect because the medication should be used before engaging in activity. Strenuous activity should be avoided. Answer (b) is incorrect because the medication should be used when pain occurs, not on a regular schedule. Answer (d) is incorrect because the medication will not prevent nocturnal angina.

Question 99.    
The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
(a) SGOTand LDH
(b) SGOTand CK BB
(c) LDH and CK MB
(d) LDH and CK BB
Answer:
(c) LDH and CK MB

Rationale:
The LDH and CK MB are specific for diagnosing cardiac damage. Answers (a), (b), and (d) are not specific to cardiac function; therefore, they are incorrect.

Question 100.    
Which of the following characterizes peer group relationships in eight- and nine-year-olds?
(a) Activities organized around competitive games 
(b) Loyalty and strong same-sex friendships 
(c) Informal socialization between boys and girls 
(d) Shared activities with one best friend
Answer:
(a) Activities organized around competitive games 

Rationale:
The school-age child (eight or nine years old) engages in cooperative play. These children enjoy competitive games in which there are rules and guidelines for winning. Answers (b) and (d) describe peer-group relationships of the preschool child, and answer (c) describes peer-group relationships of the preteen.

Question 101.    
If the school-age child is not given the opportunity to engage in tasks and activities he can carry through to completion, he is likely to develop feelings of:
(a) Guilt
(b) Shame
(c) Stagnation
(d) Inferiority
Answer:
(d) Inferiority

Rationale:
According to Erikson, the school-age child needs the opportunity to be involved in tasks that he can complete so that he can develop a sense of industry. If he is not given these opportunities, he is likely to develop feelings of inferiority. Answers (a), (b), and (c) are not associated with the psychosocial development of the school-age child; therefore, they are incorrect.

Question 102.    
The physician has ordered two units of whole blood for a client following surgery. To provide for client safety, the nurse should:
(a) Obtain a signed permit for each unit of blood.
(b) Use a new administration set for each unit transfused. 
(c) Administer the blood using a Y connector.
(d) Check the blood type and Rh factor three times before initiating the transfusion.
Answer:
(d) Check the blood type and Rh factor three times before initiating the transfusion.

Rationale:
Before initiating a transfusion, the nurse should check the identifying information, including blood type and Rh, at least three times with another staff member. It is not necessary to obtain a signed permit for each unit of blood; therefore, answer (a) is incorrect. It is not necessary to use a new administration set for each unit transfused; therefore, answer (b) is incorrect. Administering the blood using a Y connector is not related to client safety; therefore, answer (c) is incorrect.

Question 103.    
A client with B positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
(a) The available blood has been banked for two weeks.
(b) The blood available for transfusion is Rh negative.
(c) The client has a peripheral IV of D5 14 normal saline. 
(d) The blood available for transfusion is type 0 positive.
Answer:
(c) The client has a peripheral IV of D5 14 normal saline. 

Rationale:
The client should have a peripheral IV of normal saline for initiating the transfusion. Solutions containing dextrose are unsuitable for administering blood. Blood that has been banked for two weeks is suitable for transfusion; therefore, answer (a) is incorrect. The client with B positive blood can receive Rh negative and type 0 positive blood; therefore, answers (b) and (d) are incorrect.

Question 104.    
The nurse is reviewing the lab results of a client’s arterial blood gases. The PaC02 indicates effective functioning of the:
(a) Kidneys
(b) Pancreas
(c) Lungs 
(d) Liver
Answer:
(c) Lungs 

Rationale:
The PaCO₂ (partial pressure of alveolar carbon dioxide) indicates the effectiveness of the lungs. Adequate exchange of carbon dioxide is one of the major determinants in acid/base balance. Answers (a), (b), and (d) are incorrect because they are not represented by the PaCO₂.

Question 105.    
The autopsy results in SIDS-related death will show the following consistent findings:
(a) Abnormal central nervous system development 
(b) Abnormal cardiovascular development 
(c) Intraventricular hemorrhage and cerebral edema
(d) Pulmonary edema and intrathoracic hemorrhages
Answer:
(d) Pulmonary edema and intrathoracic hemorrhages

Rationale:
Although the cause remains unknown, autopsy results consistently reveal the presence of pulmonary edema and intrathoracic hemorrhages in infants dying with SIDS. Answers (a), (b), and (c) have not been linked to SIDS deaths; therefore, they are incorrect.

Question 106.    
The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs 73.5gm. The diaper's dry weight was 62gm. The newborn’s urine output is:
(a) 10mL 
(b) 11.5mL 
(c) 10gm 
(d) 12gm 
Answer:
(b) 11.5mL 

Rationale:
To obtain the urine output, the weight of the dry diaper (62g) is subtracted from the weight of the used diaper (73.5g), for a urine output of 11.5mL. Answers (a), (c), and (d) contain wrong amounts; therefore, they are incorrect.

Question 107.    
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
(a) Additional calcium in the infant’s diet 
(b) Careful handling to prevent fractures 
(c) Providing extra sensorimotor stimulation 
(d) Frequent testing of visual function
Answer:
(b) Careful handling to prevent fractures 

Rationale:
The infant with osteogenesis imperfecta (ribbon bones) should be handled with care, to prevent fractures. Adding calcium to the infant’s diet will not improve the condition; therefore, answer (a) is incorrect. Answers (c) and (d) are not related to the disorder, so they are incorrect.

Question 108.    
A newborn is diagnosed with respiratory distress syndrome (RDS). Which position is best for maintaining an open airway?
(a) Prone, with his head turned to one side.
(b) Side-lying, with a towel beneath his shoulders.
(c) Supine, with his neck slightly flexed.
(d) Supine, with his neck slightly extended.
Answer:
(d) Supine, with his neck slightly extended.

Rationale:
Placing the infant supine with the neck slightly extended helps to maintain an open airway. Answers (a), (b), and (c) are incorrect because they do not help to maintain an open airway.

Question 109.    
A client with bipolar disorder is discharged with a prescription for Depakote (divalproex sodium). The nurse should remind the client of the need for:
(a) Frequent dental visits 
(b) Frequent lab work 
(c) Additional fluids 
(d) Additional sodium
Answer:
(b) Frequent lab work 

Rationale:
Adverse reactions to Depakote (divalproex sodium) include thrombocytopenia, leukopenia, bleeding tendencies, and hepatotoxicity; therefore, the client will need frequent lab work. Answer (a) is associated with the use of Dilantin (phenytoin), and answers (c) and (d) are associated with the use of Eskalith (lithium carbonate); therefore, they are incorrect.

Question 110.    
The physician’s notes state that a client with cocaine addiction has formication. The nurse recognizes that the client has:
(a) Tactile hallucinations 
(b) Irregular heart rate 
(c) Paranoid delusions 
(d) Methadone tolerance
Answer:
(a) Tactile hallucinations 

Rationale:
The client with cocaine addiction frequently reports formication, or “cocaine bugs,” which are tactile hallucinations. Answers (b) and (c) occur in those addicted to cocaine but do not refer to formication; therefore, they are incorrect. Answer (d) is not related to the formication; therefore, it is incorrect.

Question 111.    
The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
(a) Eat a small snack before bedtime 
(b) Sleep on his right side 
(c) Avoid carbonated beverages 
(d) Increase his intake of citrus fruits 
Answer:
(c) Avoid carbonated beverages 

Rationale:
Carbonated beverages increase the pressure in the stomach and increase the incidence of gastroesophageal reflux. Answer (a) is incorrect because the client with GERD should not eat 3-4 hours before going to bed. Answer (b) is incorrect because the client should sleep on his left side to prevent reflux. Answer (d) is incorrect because spicy, acidic foods and beverages are irritating to the gastric mucosa.

Question 112.    
A client with a C₃ spinal cord injury experiences autonomic hyper- reflexia. After placing the client in high Fowler’s position, the    
(a) Notify the physician
(b) Make sure the catheter is patent
(c) Administer an antihypertensive
(d) Provide supplemental oxygen
Answer:
(b) Make sure the catheter is patent

Rationale:
After raising the client’s head to lower the blood pressure, the nurse should make sure that the catheter is patent. Answers (a) and (c) are not the first or second actions the nurse should take; therefore, they are incorrect. The client with autonomic hyperreflexia has an extreme elevation in blood pressure. The use of supplemental oxygen 

Question 113.    
A client is to receive Dilantin (phenytoin) via a nasogastric (NG) tube. When giving the medication, the nurse should:    
(a) Flush the NG tube with 2-4mL of water before giving the medication
(b) Administer the medication, flush with 5mL of water, and clamp the NG tube
(c) Flush the NG tube with 5mL of normal saline and administer the medication
(d) Flush the NG tube with 2-4oz of water before and after giving the medication
Answer:
(d) Flush the NG tube with 2-4oz of water before and after giving the medication

Rationale:
The nurse should flush the NG tube with 2-4oz of water before and after giving the medication. Answers (a) and (b) are incorrect because they do not use sufficient amounts of water. Answer (c) is incorrect because water, not normal saline, is used to flush the NG tube.

Question 114.    
When assessing the client with acute arterial occlusion, the nurse would expect to find:    
(a) Peripheral edema in the affected extremity 
(b) Minute blackened areas on the toes 
(c) Pain above the level of occlusion 
(d) Redness and warmth over the affected area
Answer:
(b) Minute blackened areas on the toes 

Rationale:
Acute arterial occlusion results in blackened or gangrenous areas on the toes. Answer (a) is incorrect because it describes venous occlusion. Answer (c) is incorrect because the pain is located below the level of occlusion. Answer (d) is incorrect because the area is cool, pale, and pulseless.

Question 115.    
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and  that the urine is very dilute. The nurse should give priority to:
(a) Notifying the doctor immediately 
(b) Documenting the finding in the chart 
(c) Decreasing the rate of IV fluids 
(d) Administering vasopressive medication
Answer:
(a) Notifying the doctor immediately 

Rationale:
The client’s symptoms suggest the development of diabetes insipidus, which can occur with surgery on or near the pituitary. Although the finding will be documented in the chart, it is not the main priority at this time; therefore, answer (b) is incorrect. Answers (c) and (d) must be ordered by the doctor, making them incorrect.

Question 116.    
The physician has ordered Coumadin (sodium warfarin) for a client with a history of clots. The nurse should tell the client to  avoid which of the following vegetables?
(a) Lettuce    
(b) Cauliflower    
(c) Beets    
(d) Carrots    
Answer:
(b) Cauliflower    

Rationale:
The client taking Coumadin (sodium warfarin) should limit his intake of vegetables such as cauliflower, cabbage, spinach, turnip greens, and collards because they are high in vitamin K. Answers (a), (c), and (d) do not contain large amounts of vitamin K; thus, they are incorrect.

Question 117.    
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
(a) Use a small hand-held hair dryer set on medium heat. 
(b) Place a small heater near the child’s bed.
(c) Turn the child at least every two hours.
(d) Allow one side to dry before changing positions.
Answer:
(c) Turn the child at least every two hours.

Rationale:
Turning the child every two hours will help the cast to dry and help prevent complications related to immobility. Answers (a) and (b) are incorrect because the cast will transmit heat to the child, which can result in burns. External heat prevents complete drying of the cast because the outside will feel dry while the inside remains wet. Answer (d) is incorrect because the child should be turned at least every two hours.

Question 118.    
The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is given annually in:
(a) November
(b) December
(c) January
(d) February
Answer:
(a) November

Rationale:
The influenza vaccine is usually given in October and November. Answers (b), (c), and (d) are inaccurate, so they are incorrect.

Question 119.
A client is admitted with suspected Hodgkin’s lymphoma. The diagnosis is confirmed by the:
(a) Overproliferation of immature white cells
(b) Presence of Reed-Sternberg cells
(c) Increased incidence of microcytosis
(d) Reduction in the number of platelets
Answer:
(b) Presence of Reed-Sternberg cells

Rationale:
The presence of Reed-Sternberg cells, sometimes referred to as “owl’s eyes,” are diagnostic for Hodgkin’s lymphoma. Answers (a), (c), and (d) are not associated with Hodgkin’s lymphoma and are incorrect.

Question 120.
The nurse is caring for a client following a laryngectomy. The best help the client with communication by:
(a) Providing a pad and pencil
(b) Checking on him every 30 minutes
(c) Telling him to use the call light
(d) Teaching the client simple sign language
Answer:
(a) Providing a pad and pencil

Rationale:
Providing the client a pad and pencil allows him a way to communicate with the nurse. Answers (b) and (c) are important in the client’s care; however, they do not provide a means for the client to “talk” with the nurse. Answer (d) is not realistic and is likely to be frustrating to the client, so it is incorrect.

Question 121.
A client has recently been diagnosed with open-angle glaucoma. The nurse should tell the client to avoid taking:
(a) Aleve (naprosyn)
(b) Benadryl (diphenhydramine)
(c) Tylenol (acetaminophen)
(d) Robitussin (guaifenesin)
Answer:
(b) Benadryl (diphenhydramine)

Rationale:
Antihistamines should not be used by the client with open-angle glaucoma because they dilate the pupil and prevent the outflow of aqueous humor, which raises pressures in the eye. Answers (a), (c), and (d) are safe for use in the client with open-angle glaucoma; therefore, they are incorrect.

Question 122.    
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client’s condition is related to:
(a) Living in an area where the soil is depleted    of iodine
(b) Eating foods that decrease the thyroxine level
(c) Using aluminum cookware to prepare the family’s meals
(d) Taking medications that decrease the thyroxine level
Answer:
(a) Living in an area where the soil is depleted    of iodine

Rationale:
Persons with endemic goiter live in areas where the soil is depleted of iodine. Answers (b) and (d) refer to sporadic goiter, and answer (c) is not related to the occurrence of goiter.

Question 123.    
A client with a history of schizophrenia is seen in the local health clinic for medication follow-up. To maintain a therapeutic level of medication, the nurse should tell the client to avoid:
(a) Taking over-the-counter allergy medication
(b) Eating cheese and pickled foods
(c) Eating salty foods
(d) Taking over-the-counter pain relievers
Answer:
(a) Taking over-the-counter allergy medication

Rationale:
The client should avoid over-the-counter allergy medications because many of them contain Benadryl (diphenhydramine). Benadryl is used to counteract the effects of antipsychotic medications that are prescribed for schizophrenia. Answer (b) refers to the client taking an MAO inhibitor, and answer (c) refers to the client taking lithium; therefore, they are incorrect. Over-the-counter pain relievers are safe for the client taking antipsychotic medication, so answer (d) is incorrect.

Question 124.    
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
(a) Body image disturbance related to enlargement of the neck
(b) Activity intolerance related to fatigue
(c) Nutrition imbalance, less than body requirements, related to increased metabolism
(d) Risk for ineffective airway clearance related to pressure of goiter on the trachea
Answer:
(d) Risk for ineffective airway clearance related to pressure of goiter on the trachea

Rationale:
The priority nursing diagnosis for the client with a goiter is risk for ineffective airway clearance related to pressure of the goiter on the trachea. Answers (a), (b), and (c) apply to the client with a goiter; however, they do not take priority over airway clearance and are therefore incorrect choices.

Question 125.    
Upon arrival to the nursery, erythromycin eyedrops are applied to the newborn’s eyes. The nurse understands that the medication will:
(a) Make the eyes less sensitive to light 
(b) Help prevent neonatal blindness 
(c) Strengthen the muscles of the eyes 
(d) Improve accommodation to near objects
Answer:
(b) Help prevent neonatal blindness 

Rationale:
The purpose of applying Erythromycin eyedrops to the new born’s eyes is to prevent neonatal blindness that can result from contamination with Neisseria gonorrhoeae. Answers (a), (c), and (d) are inaccurate statements and, therefore, are incorrect.

Question 126.    
A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
(a) Produces changes in the kidneys 
(b) Is confined to changes in the skin 
(c) Results in damage to the heart and lungs 
(d) Affects both joints and muscles 
Answer:
(b) Is confined to changes in the skin 

Rationale:
Discoid lupus produces discoid or “coinlike” lesions on the skin. Answers (a), (c), and (d) refer to systemic lupus; therefore, they are incorrect.

Question 127.    
A client sustained a severe head injury to the occipital lobe. The nurse should carefully assess the client for:
(a) Changes in vision
(b) Difficulty in speaking
(c) Impaired judgment
(d) Hearing impairment
Answer:
(a) Changes in vision

Rationale:
The visual center of the brain is located in the occipital lobe, so damage to that region results in changes in vision. Answers (b) and (d) are associated with the temporal lobe, and answer (c) is associated with the frontal lobe.

Question 128.    
The nurse observes a group of toddlers at daycare. Which of the following play situations exhibits the characteristics of parallel play?
(a) Lindie and Laura sharing clay to make cookies 
(b) Nick and Matt playing beside each other with trucks 
(c) Adrienne working a puzzle with Meredith and Ryan
(d) Ashley playing with a busy box while sitting in her crib
Answer:
(b) Nick and Matt playing beside each other with trucks 

Rationale:
Parallel play, the form of play used by toddlers, involves playing beside one another with like toys but without interaction. Answer (a) is incorrect because it describes associative play, typical of the preschooler. Answer (c) is incorrect because it describes cooperative play, typical play of the school-age child. Answer (d) is incorrect because it describes solitary play, typical play of the infant.

Question 129.    
Which of the following statements is true regarding language development of young children?
(a) Infants can discriminate speech from other patterns of sound.
(b) Boys are more advanced in language development than girls of the same age.
(c) Second-born children develop language earlier than first-born or only children.
(d) Using single words for an entire sentence suggests delayed speech development.
Answer:
(a) Infants can discriminate speech from other patterns of sound.

Rationale:
Infants can discriminate speech and the human voice from other patterns of sound. Answers (b), (c), and (d) are inaccurate statements; therefore, they are incorrect.

Question 130.    
A mother tells the nurse that her daughter has become quite a col-lector, filling her room with Beanie babies, dolls, and stuffed ani-mals. The nurse recognizes that the child is developing:
(a) Object permanence 
(b) Post-conventional thinking 
(c) Concrete operational thinking 
(d) Pre-operational thinking
Answer:
(c) Concrete operational thinking 

Rationale:
As the school-age child develops concrete operational thinking, she becomes more selective and discriminating in her collections. Answer (a) refers to the cognitive development of the infant; answer (b) refers to moral, not cognitive, development; and answer (d) refers to the cognitive development of the toddler and preschool child. Therefore, all are incorrect.

Question 131.    
According to Erikson, the developmental task of the infant is to establish trust. Parents and caregivers foster a sense of trust by:
(a) Holding the infant during feedings 
(b) Speaking quietly to the infant 
(c) Providing sensory stimulation 
(d) Consistently responding to needs 
Answer:
(d) Consistently responding to needs 

Rationale:
Consistently responding to the infant’s needs fosters a sense of trust. Failure or inconsistency in meeting the infant’s needs results in a sense of mistrust. Answers (a), (b), and (c) are important to the development of the infant but do not necessarily foster a sense of trust; therefore, they are incorrect.

Question 132.    
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
(a) Give the client pain medication.
(b) Assist the client in dangling her legs.
(c) Have the client breathe deeply.
(d) Provide the client additional fluids.
Answer:
(b) Assist the client in dangling her legs.

Rationale:
Before walking the client for the first time after delivery, the nurse should ask the client to sit on the side of the bed and dangle her legs, to prevent postural hypotension. Pain medication should not be given before walking, making answer (a) incorrect. Answers (c) and (d) have no relationship to walking the client, so they are incorrect.

Question 133.    
To minimize confusion in the elderly hospitalized client, the nurse should:
(a) Provide sensory stimulation by varying the daily routine.
(b) Keep the room brightly lit and the television on to provide orientation to time.
(c) Encourage visitors to limit visitation to phone calls to avoid overstimulation.
(d) Provide explanations in a calm, caring manner to minimize anxiety.
Answer:
(d) Provide explanations in a calm, caring manner to minimize anxiety.

Rationale:
Hospitalized elderly clients frequently become confused. Providing simple explanations in a calm, caring manner will help minimize anxiety and confusion. Answers (a) and (b) will increase the client’s confusion, and answer (c) is incorrect because personal visits from family and friends would benefit the client.

Question 134.    
A client diagnosed with tuberculosis asks the nurse when he can return to work. The nurse should tell the client that:
(a) He can return to work when he has three negative sputum cultures.
(b) He can return to work as soon as he feels well enough.
(c) He can return to work after a week of being on the medication.
(d) He should think about applying for disability because he will no longer be able to work.
Answer:
(a) He can return to work when he has three negative sputum cultures.

Rationale:
The client can return to work when he has three negative sputum cultures. Answers (b), (c), and (d) are inaccurate statements, so they are incorrect.

Question 135.    
The physician has ordered lab work for a client with suspected disseminated intravascular coagulation (DIC). Which lab finding would provide a definitive diagnosis of DIC?
(a) Elevated erythrocyte sedimentation rate
(b) Prolonged clotting time
(c) Presence of fibrin split compound
(d) Elevated white cell count 
Answer:
(c) Presence of fibrin split compound

Rationale:
The presence of fibrin split compound provides a definitive diagnosis of DIC. An elevated erythrocyte sedimentation rate is associated with inflammatory diseases; therefore, answer (a) is incorrect. Answer (b) is incorrect because the client with DIC clots too readily, forming microscopic thrombi. Answer (d) is incorrect because an elevated white cell count is associated with infection.

Question 136.    
The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client’s symptoms will be most improved by:
(a) Taking a warm shower upon awakening 
(b) Applying ice packs to the joints 
(c) Taking two aspirin before going to bed 
(d) Going for an early morning walk
Answer:
(a) Taking a warm shower upon awakening 

Rationale:
The symptoms of rheumatoid arthritis are worse upon awakening. Taking a warm shower helps relieve the stiffness and soreness associated with the disease. Answer (b) is incorrect because heat is the most beneficial way of relieving the symptoms. Large doses of aspirin are given in divided doses throughout the day, making answer (c) incorrect. Answer (d) is incorrect because the client has more problems with mobility early in the morning.

Question 137.    
A client with schizophrenia has been taking Clozaril (clozapine) for the past six months. This morning the client’s temperature was elevated to 102°F. The nurse should give priority to:
(a) Placing a note in the chart for the doctor 
(b) Rechecking the temperature in four hours 
(c) Notifying the physician immediately 
(d) Asking the client if he has been feeling sick
Answer:
(c) Notifying the physician immediately 

Rationale:
Temperature elevations in the client receiving antipsychotics (sometimes referred to as neuroleptics) such as Clozaril (clozapine) should be reported to the physician immediately. Antipsychotics can produce adverse reactions that include dystonia, agranulocytosis, and neuromalignant syndrome (l\IMS). Answers (a) and (b) are incorrect because they jeopardize the safety of the client. Answer (d) is incorrect because the client with schizophrenia is often unaware of his condition; therefore, the nurse must rely on objective signs of illness.

Question 138.    
Which one of the following clients is most likely to develop acute respiratory distress syndrome?
(a) A 20-year-old with fractures of the tibia 
(b) A 36-year-old who is HIV positive 
(c) A 40-year-old with duodenal ulcers 
(d) A 32-year-old with barbiturate overdose
Answer:
(d) A 32-year-old with barbiturate overdose

Rationale:
Drug overdose is a primary cause of acute respiratory distress syndrome. Answers (a), (b), and (c) are incorrect because they are not associated with the development of acute respiratory distress syndrome.

Question 139.    
The complete blood count of a client admitted with anemia reveals that the red blood cells are hypochromic and microcytic. The nurse recognizes that the client has:
(a) Aplastic anemia 
(b) Iron-deficiency anemia 
(c) Pernicious anemia 
(d) Hemolytic anemia
Answer:
(b) Iron-deficiency anemia 

Rationale:
With iron-deficiency anemia, the RBCs are described as hypochromic and microcytic. Answer (a) is incorrect because the RBCs would be normochromic and normocytic but would be reduced in number. Answer (c) is incorrect because the RBCs would be normochromic and macrocytic. Answer (d) refers to anemias due to an abnormal shape or shortened life span of the RBCs rather than the color or size of the RBC; therefore, it is incorrect.

Question 140.    
While performing a neurological assessment on a client with a closed head injury, the nurse notes a positive Babinski reflex. The nurse should:
(a) Recognize that the client’s condition is improving.
(b) Reposition the client and check reflexes again.
(c) Do nothing because the finding is an expected one.
(d) Notify the physician of the finding.
Answer:
(d) Notify the physician of the finding.

Rationale:
A positive Babinski reflex in adults should be reported to the physician because it indicates a lesion of the corticospinal tract. Answer (a) is incorrect because it does not indicate that the client’s condition is improving. Answer (b) is incorrect because changing the position will not alter the finding. Answer (c) is incorrect because a positive Babinski reflex is an expected finding in an infant, but not in an adult.

Question 141.    
The doctor has ordered neurological checks every 30 minutes for a client injured in a biking accident. Which finding indicates that the client’s condition is satisfactory?
(a) A score of 13 on the Glascow coma scale 
(b) The presence of doll’s eye movement 
(c) The absence of deep tendon reflexes 
(d) Decerebrate posturing
Answer:
(a) A score of 13 on the Glascow coma scale 

Rationale:
The Glascow coma scale, which measures verbal response, motor response, and eye opening, ranges from 0 to 15. A score of 13 indicates the client's condition is satisfactory. Answer (b) is incorrect because the presence of doll’s eye movement indicates damage to the brainstem or oculomotor nerve. Answer (c) is incorrect because absent deep tendon reflexes are associated with deep coma. Answer (d) is incorrect because decerebrate posturing is associated with injury to the brain stem.

Question 142.    
The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
(a) Optimal restoration of the client’s elimination pattern 
(b) Restoration of the client’s neurosensory function 
(c) Prevention of complications from impaired elimination 
(d) Promotion of a positive body image
Answer:
(c) Prevention of complications from impaired elimination 

Rationale:
The primary goal of a bowel and bladder retraining program is to prevent complications that can result from impaired elimination. Answer (a) is incorrect because the retraining will not restore the client’s preinjury elimination pattern. Answer (b) is incorrect because the retraining will not restore the client’s neurosensory function. The client’s body image will improve with retraining; however, it is not the primary goal, so answer (d) is incorrect.

Question 143.    
When checking patellar reflexes, the nurse is unable to elicit a knee-jerk response. To facilitate checking the patellar reflex, the nurse should tell the client to:
(a) Pull against her interlocked fingers
(b) Shrug her shoulders and hold for a count of five 
(c) Close her eyes tightly and resist opening 
(d) Cross her legs at the ankles
Answer:
(a) Pull against her interlocked fingers

Rationale:
Pulling against interlocked fingers will focus the client’s attention away from the area being examined, thus making it easier to elicit a knee-jerk response. Answer (b) is incorrect because it is a means of checking the spinal accessory nerve. Answer (c) is incorrect because it is a means of checking the oculomotor nerve. Answer (d) is incorrect because it will not facilitate checking the patellar reflex.

Question 144.    
The nurse is performing a physical assessment on a newly admit-ted client. The last step in the physical assessment is:
(a) Inspection
(b) Auscultation
(c) Percussion
(d) Palpation
Answer:
(b) Auscultation

Rationale:
Auscultation is the last step performed in a physical assessment. Answers (a), (c), and (d) are incorrect because they are performed before auscultation.

Question 145.    
A client with schizophrenia spends much of his time pacing the floor, rocking back and forth, and moving from one foot to another. The client’s behaviors are an example of:
(a) Dystonia
(b) Tardive dyskinesia
(c) Akathisia
(d) Oculogyric crisis 
Answer:
(c) Akathisia

Rationale:
Akathesia, an extrapyramidal side effect of antipsychotic medication, results in an inability to sit still or stand still. Dystonia, in answer (a), refers to a muscle spasm in any muscle of the body; answer (b) refers to abnormal, involuntary movements of the face, neck, and jaw; and answer (d) refers to an involuntary deviation and fixation of the eyes; therefore, they are incorrect.

Question 146.    
The nurse is assessing a recently admitted newborn. Which finding should be reported to the physician?
(a) The umbilical cord contains three vessels.
(b) The newborn has a temperature of 98°F.
(c) The feet and hands are bluish in color.
(d) A large, soft swelling crosses the suture line.
Answer:
(d) A large, soft swelling crosses the suture line.

Rationale:
The large soft swelling that crosses the suture line indicates that the newborn has a caput succedaneum. This finding should be reported to the physician. Answer (a) is incorrect because the umbilical cord normally contains three vessels (two arteries and one vein). Answer (b) is incorrect because the temperature is normal for the newborn. Answer (c) refers to acrocyanosis, which is normal in the newborn.

Question 147.    
Which statement is true regarding the infant’s susceptibility to pertussis?
(a) If the mother had pertussis, the infant will have passive immunity.
(b) Most infants and children are highly susceptible from birth.
(c) The newborn will be immune to pertussis for the first few months of life.
(d) Infants under one year of age seldom get pertussis.
Answer:
(b) Most infants and children are highly susceptible from birth.

Rationale:
Infants and children are highly susceptible to infection with pertussis. Answers (a), (c), and (d) are inaccurate statements; therefore, they are incorrect.

Question 148.    
A client in labor has been given epidural anesthesia with Marcaine (bupivacaine). To reverse the hypotension associated with epidural anesthesia, the nurse should have which medication available?
(a) Narcan (naloxone)
(b) Dobutrex (dobutamine)
(c) Romazicon (flumazenil)
(d) Adrenalin (epinephrine)
Answer:
(d) Adrenalin (epinephrine)

Rationale:
Epidural anesthesia produces vasodilation and lowers the blood pressure; therefore, adrenalin should be available to reverse hypotension. Answer (a) is incorrect because it is a narcotic antagonist. Answer (b) is incorrect because it is an adrenergic that increases cardiac output. Answer (c) is incorrect because it is a benzodiazepine antagonist.

Question 149.    
The physician has prescribed Gantrisin (sulfasoxazole) 1gm in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
(a) With meals or a snack 
(b) 30 minutes before meals 
(c) 30 minutes after meals 
(d) At bedtime
Answer:
(b) 30 minutes before meals 

Rationale:
Gantrisin and other sulfa drugs should be given 30 minutes before meals, to enhance absorption. Answer (a) is incorrect because the medication should be given before eating. Answer (c) is incorrect because the medication should be given on an empty stomach. Answer (d) is incorrect because the medication is to be given in divided doses throughout the day.

Question 150.    
A client with a history of depression is treated with Parnate (tranylcypromine), an MAO inhibitor. Ingestion of foods containing tyramine while taking an MAO inhibitor can result in:
(a) Extreme elevations in blood pressure 
(b) Rapidly rising temperature 
(c) Abnormal movement and muscle spasms 
(d) Damage to the eighth cranial nerve
Answer:
(a) Extreme elevations in blood pressure 

Rationale:
The client taking Parnate and other MAO inhibitors should avoid ingesting foods containing tyramine, which can result in extreme elevations in blood pressure. Answers (b), (c), and (d) are not associated with the use of MAO inhibitors; therefore, they are incorrect.

Question 151.    
A client is admitted to the emergency room after falling down a flight of stairs. Initial assessment reveals a large bump on the front of the head and a two-inch laceration above the right eye. Which finding is consistent with injury to the frontal lobe?
(a) Complaints of blindness
(b) Decreased respiratory rate and depth
(c) Failure to recognize touch
(d) Inability to identify sweet taste
Answer:
(c) Failure to recognize touch

Rationale:
The frontal lobe interprets sensation, so the client’s failure to recognize touch confirms a frontal lobe injury. Answer (a) is incorrect because the occipital lobe is the visual center. Answer (b) is incorrect because the medulla is the respiratory center. Taste impulses are interpreted in the parietal lobe; therefore, answer (d) is incorrect.

Question 152.    
The nurse is evaluating the intake and output of a client for the first 12 hours following an abdominal cholecystectomy. Which finding should be reported to the physician?
(a) Output of 10mL from the Jackson-Pratt drain 
(b) Foley catheter output of 285mL 
(c) Nasogastric tube    output of 150mL
(d) Absence of stool
Answer:
(b) Foley catheter output of 285mL 

Rationale:
The normal urinary output is 30-50mL per hour. The client’s urinary output is below normal, indicating that additional fluids are needed. The amount of output from the Jackson-Pratt drain should be small; therefore, answer (a) is incorrect. The amount of drainage from the nasogastric tube is not excessive, so answer (c) is incorrect. Answer (d) is incorrect because the client would not be expected to have a stool in the first 12 hours following surgery.

Question 153.    
A community health nurse is teaching healthful lifestyles to a group of senior citizens. The nurse knows that the leading cause of death in persons 65 and older is:
(a) Chronic pulmonary    disease
(b) Diabetes mellitus
(c) Pneumonia 
(d) Heart disease
Answer:
(d) Heart disease

Rationale:
According to the National Center for Health Statistics, heart disease is the number one cause of death in persons 65 and older. Chronic pulmonary disease is the fourth-leading cause of death in this age group; therefore, answer (a) is incorrect. Diabetes mellitus is the sixth-leading cause of death in this age group, and pneumonia is the fifth-leading cause of death in this age group; therefore, answers (b) and (c) are incorrect.

Question 154.    
A client suspected of having Alzheimer’s disease is evaluated using the Mini-Mental State Examination. At the beginning of the evaluation, the examiner names three objects. Later in the evalua-tion, he asks the client to name the same three objects. The exam-iner is testing the client’s:
(a) Attention 
(b) Orientation 
(c) Recall 
(d) Registration 
Answer:
(c) Recall 

Rationale:
Recall is the client’s ability to restate items mentioned at the beginning of the evaluation. Attention is evaluated by having the client count backward by 7 beginning at 100, so answer (a) is incorrect. Orientation is evaluated by having the client state the year, month, date, and day, so answer (b) is incorrect. Registration is evaluated by having the client immediately repeat the name of three items just named by the examiner; thus, answer (d) is incorrect.

Question 155.    
A client with end stage renal disease is being managed with peri-toneal dialysis. If the dialysate return is slowed the nurse should tell the client to:
(a) Irrigate the dialyzing catheter with saline.
(b) Skip the next scheduled infusion.
(c) Gently retract the dialyzing catheter.
(d) Change position or turn side to side.
Answer:
(d) Change position or turn side to side.

Rationale:
The nurse should tell the client to change position or turn side to side in order to improve the dialysate return. Answers (a), (b), and (c) are incorrect ways of managing peritoneal dialysis; therefore, they are incorrect choices.

Question 156.    
The nurse is the first person to arrive at the scene of a motor vehicle accident. When rendering aid to the victim, the nurse should give priority to:
(a) Establishing a patent airway 
(b) Checking the quality of respirations 
(c) Observing for signs of active bleeding
(d) Determining the level of consciousness
Answer:
(a) Establishing a patent airway 

Rationale:
The nurse should give priority to maintaining the client’s airway. The ABCDs of trauma care are airway with cervical spine immobilization, breathing, circulation, and disabilities (neurological); therefore, answers (b), (c), and (d) are incorrect.

Question 157.    
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client’s vital signs that include:
(a) Decreased pulse rate
(b) Increased blood pressure
(c) Decreased respiratory rate
(d) Increased temperature
Answer:
(b) Increased blood pressure

Rationale:
The client in pain usually has an increased blood pressure. Answers (a) and (c) are incorrect because the client in pain will have an increased pulse rate and increased respiratory rate. Temperature is not affected by pain; therefore, answer (d) is incorrect.

Question 158.    
The nurse is using the Glascow coma scale to assess the client's motor response. The nurse places pressure at the base of the client’s fingernail for 20 seconds. The client’s only response is withdrawal of his hand. The nurse interprets the client’s response as:
(a) A score of 6 because he follows commands
(b) A score of 5 because he localizes pain
(c) A score of 4 because he uses flexion
(d) A score of 3 because he uses extension
Answer:
(c) A score of 4 because he uses flexion

Rationale:
A score of 4 indicates normal flexion. Normal flexion caused the client to withdraw his whole hand from the stimuli. Answers (a), (b), and (d) are incorrect because they do not relate to the client’s response to the stimulus.

Question 159.    
A four-year-old is admitted to the hospital for treatment of Kawasaki's disease. The medication commonly prescribed for the treatment of Kawasaki’s disease is:
(a) Aspirin (acetylsalicylic acid)
(b) Benadryl (diphenhydramine)
(c) Polycillin (ampicillin)
(d) Betaseron (interferon beta) 
Answer:
(a) Aspirin (acetylsalicylic acid)

Rationale:
Management of Kawasaki’s disease includes the use of large doses of aspirin. Answers (b), (c), and (d) are incorrect because they are not used in the treatment of Kawasaki’s disease.

Question 160.    
The nurse is caring for a client with bulimia nervosa. The nurse recognizes that the major difference in the client with anorexia nervosa and the client with bulimia nervosa is the client with bulimia:
(a) Is usually grossly overweight.
(b) Has a distorted body image.
(c) Recognizes that she has an eating disorder.
(d) Struggles with issues of dependence versus independence. 
Answer:
(c) Recognizes that she has an eating disorder.

Rationale:
The client with bulimia nervosa recognizes that she has an eating disorder but feels helpless to correct it. Answer (a) is incorrect because the client with bulimia nervosa is usually of normal weight. Answers (b) and (d) are incorrect because they describe both the client with anorexia nervosa and the client with bulimia nervosa.
  
 Question 161.    
 The Mantoux text is used to determine whether a person has been exposed to tuberculosis. If the test is positive, the nurse will find a:            
(a) Fluid-filled vesicle
(b) Sharply demarcated erythema
(c) Central area of induration
(d) Circular blanched area
Answer:
(c) Central area of induration

Rationale:
A positive Mantoux test is indicated by the presence of induration. Answers (a), (b), and (d) are incorrect because they do not describe the findings of a positive Mantoux test.

Question 162.
The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should:
(a) Hang the solution 2-3 feet above the client’s abdomen.
(b) Allow air from the solution tubing to flow into the catheter.
(c) Use a clean technique when attaching the solution tubing to the catheter.
(d) Clamp the solution tubing periodically to prevent bladder distention.
Answer:
(a) Hang the solution 2-3 feet above the client’s abdomen.

Rationale:
The solution bag should be hung 2-3 feet above the client’s abdomen to allow a slow, steady irrigation. Answer (b) is incorrect because it will distend the bladder and cause trauma. Answer (c) is incorrect because the nurse should use sterile technique when attaching the tubing. Answer (d) is incorrect because it would be an intermittent irrigation rather than a continuous one.

Question 163.    
A pediatric client is admitted to the hospital for treatment of diarrhea caused by an infection with salmonella. Which of the following most likely contributed to the child’s illness?
(a) Brushing the family dog
(b) Playing with a turtle
(c) Taking a pony ride
(d)Feeding the family cat
Answer:
(b) Playing with a turtle

Rationale:
Salmonella infection is commonly associated with turtles and reptiles. Answers (a), (c), and (d) are incorrect because they are not sources of salmonella infection.

Question 164.    
Which one of the following infants needs a further assessment of growth?
(a) four-month-old: birth weight 7lb, 6oz; current weight 141b, 4oz
(b) two-week-old: birth weight 61b, 10oz; current weight 6lb, 12oz
(c) six-month-old: birth weight 8lb, 8oz; current weight 151b
(d) two-month-old: birth weight 71b, 2oz; current weight 91b, 6oz
Answer:
(b) two-week-old: birth weight 61b, 10oz; current weight 6lb, 12oz

Rationale:
The infant is not gaining weight as he should. Further assessment of feeding patterns as well as organic causes for growth failure should be investigated. Answers (a), (c), and (d) are incorrect because they are within the expected range for growth.

Question 165.    
The physician has ordered Pyridium (phenazopyridine) for a client with urinary urgency. The nurse should tell the client that:
(a) The urine will have a strong odor of ammonia.
(b) The urinary output will increase in amount.
(c) The urine will have a red-orange color.
(d) The urinary output will decrease in amount.
Answer:
(c) The urine will have a red-orange color.

Rationale:
Pyridium causes the urine to become red-orange in color, so the client should be informed of this. Answers (a), (b), and (d) are not associated with the use of Pyridium; therefore, they are incorrect.

Question 166.    
The nurse is teaching the mother of an six-mont-old with eczema. Which instruction should be included in the nurse’s teaching?
(a) Dress the infant warmly to prevent undue chilling.
(b) Cut the infant’s fingernails and toenails regularly.
(c) Use bubble bath instead of soap for bathing the infant.
(d) Wash the infant’s clothes with mild detergent and fabric softener.
Answer:
(b) Cut the infant’s fingernails and toenails regularly.

Rationale:
The infant’s fingernails and toenails should be kept short to prevent scratching the skin. Answers (a), (c), and (d) are incorrect because keeping the infant warm will increase itching; bubble bath and perfumed soaps should not be used because they can cause skin irritations; and the infant’s clothes should be washed in mild detergent and rinsed in plain water to reduce skin irritations.

Question 167.    
Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to:
(a) Realign the tibia and fibula.
(b) Provide traction on the muscles.
(c) Provide traction on the ligaments.
(d) Realign femoral bone fragments.
Answer:
(d) Realign femoral bone fragments.

Rationale:
Skeletal traction is used to realign bone fragments. Answer (a) is incorrect because it does not apply to the fractures of the femur. Answers (b) and (C) refer to skin traction, so they are incorrect.

Question 168.    
The home health nurse is visiting a client with an exacerbation of rheumatoid arthritis. To prevent deformities of the knee joints, the nurse should:
(a) Tell the client to walk without bending the knees.
(b) Encourage movement within the limits of pain.
(c) Instruct    the client to sit only in a recliner.
(d) Tell the client to    remain in bed as long as the joints are painful. 
Answer:
(b) Encourage movement within the limits of pain.

Rationale:
The client with rheumatoid arthritis benefits from activity within the limits of pain because it decreases the likelihood of joints becoming nonfunctional. Answer (a) is incorrect because the client needs to use the knees to prevent further stiffness and disuse. Answer (c) is incorrect because the client can sit in chairs other than a recliner. Answer (d) is incorrect because it predisposes the client to further com¬plications associated with immobility.

Question 169.    
The physician has ordered Dextrose 5% in normal saline for an infant admitted with gastroenteritis. The advantage of administering the infant’s IV through a scalp vein is:
(a) The infant can be held and comforted more easily.
(b) Dextrose is best absorbed from the scalp veins.
(c) Scalp veins do not infiltrate like peripheral veins.
(d) There are few pain receptors in the infant's scalp. 
Answer:
(a) The infant can be held and comforted more easily.

Rationale:
Use of a scalp vein for IV infusions allows the infant to be picked up and held more easily. Answers (b), (c), and (d) are inaccurate statements; therefore, they are incorrect.

Question 170.    
A newborn diagnosed with bilateral choanal atresia is scheduled for surgery soon after delivery. The nurse recognizes the immediate need for surgery because the newborn:
(a) Will have difficulty swallowing
(b) Will be unable to pass meconium
(c) Will regurgitate his feedings
(d) Will be unable to breathe through his nose
Answer:
(d) Will be unable to breathe through his nose

Rationale:
The newborn with choanal atresia will not be able to breathe through his nose because of the presence of a bony obstruction that blocks the passage of air through the nares. Answers (a), (b), and (c) are not associated with choanal atresia; therefore, they are incorrect.

Question 171.    
The most appropriate means of rehydration of a seven-month-old with diarrhea and mild dehydration is:
(a) Oral rehydration therapy with an electrolyte solution
(b) Replacing milk-based formula with a lactose-free formula
(c) Administering intraveneous Dextrose 5% normal saline
(d) Offering bananas, rice, and applesauce along with oral fluids
Answer:
(a) Oral rehydration therapy with an electrolyte solution

Rationale:
The most appropriate means of rehydrating the seven-month-old with diarrhea and mild dehydration is to provide oral electrolyte solutions. Answer (b) is incorrect because formula feedings should be delayed until symptoms improve. Answer (c) is incorrect because the seven-month-old has symptoms of mild dehydration, which can be managed with oral fluid replacement. Answer (d) is incorrect because a BRAT diet (bananas, rice, applesauce, toast) is no longer recommended by some pediatricians. In the event it is used, it would be instituted after rehydration had taken place.

Question 172.    
The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
(a) Swelling of the hands and increased temperature 
(b) Increased heart rate and increased blood pressure 
(c) Swelling of the feet and increased temperature 
(d) Decreased heart rate and decreased blood pressure
Answer:
(b) Increased heart rate and increased blood pressure 

Rationale:
Signs of fluid overload in an infant include increased heart rate and increased blood pressure. Temperature would not be increased by fluid overload; therefore, answers (a) and (c) are incorrect. Heart rate and blood pressure are not decreased by fluid overload; therefore, answer (d) is incorrect.

Question 173.    
The nurse is providing care for a 10-month-old diagnosed with Wilms tumor. Most parents of infants with Wilms tumor report finding the mass when:
(a) The infant is  diapered or bathed.
(b) The infant is  unable to use his arms.
(c) The infant is unable to follow a moving object.
(d) The infant is unable to vocalize sounds. 
Answer:
(a) The infant is diapered or bathed.

Rationale:
Most parents report finding Wilms tumor when the infant is being diapered or bathed. Answers (b), (c), and (d) are not associated with Wilms tumor; therefore, they are incorrect.

Question 174.    
An obstetrical client has just been diagnosed with cardiac disease. The nurse should give priority to:
(a) Instructing the client to remain on strict bed rest 
(b) Telling the client to monitor her pulse and respirations
(c) Instructing the client to check her temperature in the evening
(d) Telling the client to weigh herself monthly
Answer:
(b) Telling the client to monitor her pulse and respirations

Rationale:
Monitoring her pulse and respirations will provide information on her cardiac status. Answer (a) is incorrect because she should not remain on strict bed rest. Answer (c) is incorrect because it does not provide information on her cardiac status. Answer (d) is incorrect because she needs to weigh more often to determine unusual gain, which could be related to her cardiac status.

Question 175.    
The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:
(a) The rate of respirations
(b) The absence of cyanosis
(c) Arterial blood gases
(d) The level of consciousness
Answer:
(c) Arterial blood gases

Rationale:
The effectiveness of oxygen therapy is best determined by arterial blood gases. Answers (a), (b), and (d) are less helpful in determining the effectiveness of oxygen therapy, so they are incorrect.

Question 176.    
A client having a colonoscopy is medicated with Versed (midazolam). The nurse recognizes that the client:
(a) Will be able to remember the procedure within 2-3 hours
(b) Will not be able to remember having the procedure done
(c) Will be able to remember the procedure within 2-3 days
(d) Will not be able to remember what occurred before the procedure
Answer:
(b) Will not be able to remember having the procedure done

Rationale:
Versed produces conscious sedation, so the client will not be able to remember having the procedure. Answers (a), (c), and (d) are inaccurate statements.

Question 177.    
The nurse is assessing a client with an altered level of conscious-ness. One of the first signs of altered level of consciousness is:
(a) Inability to perform motor activities
(b) Complaints of double vision
(c) Restlessness
(d) Unequal pupil size 
Answer:
(c) Restlessness

Rationale:
Early indicators of an altered level of consciousness include restlessness and irritability. Answer (a) is incorrect because it is a sign of impaired motor function. Answer (b) is incorrect because it is a sign of damage to the optic chiasm or optic nerve. Answer (d) is incorrect because it is a sign of increased intracranial pressure.

Question 178.    
Four clients are to receive medication. Which client should receive medication first?
(a) A client with an apical pulse of 72 receiving Lanoxin (digoxin) PO daily
(b) A client with abdominal surgery receiving Phenergan (promethazine) IM every four hours PRN for nausea and vomiting
(c) A client with labored respirations receiving a stat dose of IV Lasix (furosemide)
(d) A client with pneumonia receiving Polycillin (ampi- cillin) IVPB every six hours
Answer:
(c) A client with labored respirations receiving a stat dose of IV Lasix (furosemide)

Rationale:
The client receiving a stat dose of medication should receive his medication first. Answers (a), (b), and (d) are incorrect because they are regularly scheduled medications for clients whose conditions are more stable.

Question 179.    
The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To lessen the likelihood of the client dislodging the IV, the nurse should:
(a) Place tape completely around the extremity, with taped ends out of the client’s vision.
(b) Tell him that if he pulls out the IV, it will have to be restarted.
(c) Apply clove hitch restraints to the client’s hands.
(d) Wrap the IV site loosely with Kerlix.
Answer:
(d) Wrap the IV site loosely with Kerlix.

Rationale:
Wrapping the IV site with Kerlex removes the area from the client’s line of vision, allowing his attention to be directed away from the site. Answer (a) is incorrect because it impedes circulation at and distal to the IV site. Answer (b) is incorrect because reasoning is a cognitive function and the client has cognitive impairment. Answer (c) is incorrect because the use of restraints would require a doctor’s order, and only one hand would be restrained.

Question 180.    
A client is admitted to the emergency room with complaints of substernal chest pain radiating to the left jaw. Which ECG finding is suggestive of acute myocardial infarction?
(a) Peaked P wave 
(b) Changes in ST segment 
(c) Minimal QRS wave 
(d) Prominent U wave
Answer:
(b) Changes in ST segment 

Rationale:
Changes in the ST segment are associated with acute myocardial infraction. Peaked P waves, minimal QRS wave, and prominent U wave are not associated with acute myocardial infarction; therefore answers (a), (c), and (d) are incorrect choices.

Question 181.    
The nurse is assessing a client with a closed reduction of a frac-tured femur. Which finding should the nurse report to the physi-cian?
(a) Chest pain and shortness of breath 
(b) Ecchymosis on the side of the injured leg 
(c) Oral temperature of 99.2°F 
(d) Complaints of level two pain on a scale of five 
Answer:
(a) Chest pain and shortness of breath 

Rationale:
Chest pain and shortness of breath following a fracture of the long bones is associated with pulmonary embolus, which requires immediate intervention. Answer (b) is incorrect because ecchymosis is common following fractures. Answer (c) is incorrect because a low-grade temperature is expected because of the inflammatory response. Answer (d) is incorrect because level-two pain is expected in the client with a recent fracture.

Question 182.    
The physician has ordered a guaiac test for a client with a history of intestinal polyps. Which instruction should be given to the client regarding his diet prior to the test? 
(a) Increase the intake of whole grains and cereals.
(b) Limit the intake of dairy products.
(c) Avoid citrus juices and vitamin C.
(d) Increase foods containing omega 3 oils.
Answer:
(c) Avoid citrus juices and vitamin C.

Rationale:
The client should avoid citrus juices, vitamin C, and red meat for three days prior to the guaiac test. Answers (a), (b), and (d) are not part of the preparation of the client for a guaiac test therefore they are incorrect.

Question 183.
A client is admitted with a diagnosis of renal calculi. The nurse should give priority to:
(a) Initiating an intravenous infusion
(b) Encouraging oral fluids
(c) Administering pain medication
(d) Straining the urine
Answer:
(a) Initiating an intravenous infusion

Rationale:
The nurse should give priority to beginning intravenous fluids. Increasing the client’s fluid intake to 3,000mL per day will help prevent the obstruction of urine flow by increasing the frequency and volume of urinary output. Answer (b) is incorrect because the catheter is in the bladder and will do nothing to affect the flow of urine from the kidney. Answer (c) is important but has no effect on preventing or alleviating the obstruction of urine flow from the kidney; therefore, it is incorrect. Answer (d) is incorrect because it will help prevent the formation of some stones but will not prevent the obstruction of urine flow.

Question 184.    
 The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
(a) Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
(b) Compare the medication administration record (MAR) with the client’s room number and name on the armband.
(c) Request that a family member identify the client and then ask the client to state his name.
(d) Ask the client to state his full name and then to write his full name.
Answer:
(a) Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.

Rationale:
JCAHO guidelines state that at least two client identifiers should be used whenever administering medications or blood products, whenever samples or specimens are taken, and when providing treatments. Neither of the identifiers is to be the client’s room number. Answer (b) is incorrect because the client’s room number is not used as an identifier. Answer (c) and (d) are incorrect because the best identifiers according to the JCAHO are the client’s armband, medical record number, and/or date of birth.

Question 185.    
A client complains of sharp, stabbing pain in the right lower quadrant that is graded as level 8 on a scale of 10. The nurse knows that pain of this severity can best be managed using:
(a) Aleve (naproxen sodium)
(b) Tylenol with codeine (acetaminophen with codeine)
(c) Toradol (ketorolac)
(d) Morphine sulfate (morphine sulfate) 
Answer:
(d) Morphine sulfate (morphine sulfate) 

Rationale:
The client’s level of pain is severe and requires narcotic analgesia. Morphine, an opioid, is the strongest medication listed. Answer (a) is incorrect because it is effective only with mild pain. Answers (b) and (c) are incorrect because they are not strong enough to relieve severe pain.

Question 186.
A client has had diarrhea for the past three days. Which acid/base imbalance would the nurse expect the client to have?
(a) Respiratory alkalosis
(b) Metabolic acidosis
(c) Metabolic alkalosis
(d) Respiratory acidosis
Answer:
(b) Metabolic acidosis

Rationale:
Persistent diarrhea results in the loss of bicarbonate (base) so that the client develops metabolic acidosis. Answers (a) and (d) are incorrect because the problem of diarrhea is metabolic, not respiratory, in nature. Answer (c) is incorrect because the client is losing bicarbonate (base); therefore, he cannot develop alkalosis, caused by excess base.

Question 187.
The nurse is planning the diet of a client who is recovering from acute pancreatitis. The nurse should select foods that are
(a) High in carbohydrate and protein
(b) Low in sodium but high fat
(c) High in protein and sodium
(d) Low in fat and low protein
Answer:
(d) Low in fat and low protein

Rationale:
The client recovering from acute pancreatitis should be provided with foods that are low in fat and protein. Answers (a), (b), and (c) are incorrect because they include food sources that are not suitable for the client recovering from acute pancreatitis.

Question 188.    
The nurse is reviewing the lab reports of a client who is HIV positive. Which lab report provides information regarding the effectiveness of the client’s medication regimen?
(a) ELISA 
(b) Western Blot 
(c) Viral load 
(d) CD4 count
Answer:
(c) Viral load 

Rationale:
The viral load or viral burden test provides information on the effectiveness of the client’s medication regimen as well as progression of the disease. Answers (a) and (b) are incorrect because they are screening tests to detect the presence of HIV. Answer (d) is incorrect because it is a measure of the number of helper cells.

Question 189.    
A client taking antiretroviral drugs reports his last blood work showed a drop of 3 units in the viral load. The nurse understands that:        
(a) The virus is no longer detectable
(b) 90% of the viral load has been eliminated
(c) 95% of the viral load has been eliminated
(d) 99% of the viral load has been eliminated
Answer:
(d) 99% of the viral load has been eliminated

Rationale:
A drop of 3 units indicates that the viral load has decreased by 99%. Answer (a) is incorrect because an undetectable viral load indicates that the amount of virus is extremely low and cannot be found in the blood using current technology; however, it does not mean that the virus is gone. Answer (b) is incorrect because a drop of 1 unit indicates that the viral load has decreased by 90%. Answer (c) is incorrect because a drop of 2 units indicates that the viral load has decreased by 95%.

Question 190.    
The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:
(a) Changes in gait 
(b) Loss of concentration 
(c) Problems with speech 
(d) Seizures 
Answer:
(b) Loss of concentration 

Rationale:
Loss of memory and loss of concentration are the first signs of AIDS dementia complex. Answers (a), (c), and (d) are symptoms associated with toxoplas¬mosis encephalitis, so they are not correct.

Question 191.    
The physician has ordered Activase (alteplase) for a client admitted with a myocardial infarction. The desired effect of Activase is:
(a) Prevention of congestive heart failure
(b) Stabilization of the clot
(c) Increased tissue oxygenation
(d) Destruction of the clot
Answer:
(d) Destruction of the clot

Rationale:
Activase (alteplase) is a thrombolytic agent that destroys the clot. Answer (a) is incorrect because the medication does not prevent congestive heart failure. Answer (b) is incorrect because it does not stabilize the clot. Answer (c) is incorrect because Alteplase does not directly increase oxygenation.

Question 192.    
The mother of a two-year-old asks the nurse when she should schedule her son’s first dental visit. The nurse’s response is based on the knowledge that most children have all their deciduous teeth by:
(a) 15 months
(b) 18 months
(c) 24 months
(d) 30  months
Answer:
(d) 30 months

Rationale:
The majority of children have all their deciduous teeth by age 30 months, which should coincide with the child’s first visit with the dentist. Answers (a), (b), and (c) are incorrect because the deciduous teeth are probably not all erupted.

Question 193.    
The nurse is caring for a child with Down syndrome. Which char-acteristics are commonly found in the child with Down syndrome?
(a) Fragile bones, blue sclera, and brittle teeth
(b) Epicanthal folds, broad hands, and transpalmar creases
(c) Low posterior hairline, webbed neck, and short stature 
(d) Developmental regression and cherry-red macula
Answer:
(b) Epicanthal folds, broad hands, and transpalmar creases

Rationale:
The child with Down syndrome has epicanthal folds, broad hands, and transpalmar creases. Answer (a) describes the child with osteogenesis imperfecta, answer (c) describes the child with Turner’s syndrome, and answer (d) describes the child with Tay Sach’s disease; therefore, they are incorrect.

Question 194.    
After several hospitalizations for respiratory ailments, a six- month-old has been diagnosed as having HIV. The infant’s respiratory ailments were most likely due to:
(a) Pneumocystis carinii
(b) Cytomegalovirus
(c) Cryptosporidiosis
(d) Herpes simplex
Answer:
(a) Pneumocystis carinii

Rationale:
The most common opportunistic infection in infants and children with HIV is Pneumocystis carinii pneumonia. Answers (b), (c), and (d) are incorrect because they are not the most common cause of opportunistic infection in the infant with HIV.

Question 195.    
A client has returned from having a bronchoscopy. Before offering the client sips of water, the nurse should assess the client’s:
(a) Blood pressure 
(b) Pupilary response 
(c) Gag reflex 
(d) Pulse rate 
Answer:
(c) Gag reflex 

Rationale:
The nurse should ensure that the client’s gag reflex is intact before offering sips of water or other fluids in order to reduce the risk of aspiration. Answers (a) and (d) should be assessed because the client has returned from having a diagnostic procedure, but they are not related to the question; therefore, they are incorrect. Answer (b) is not related to the question, so it is incorrect.
  
Question 196.    
The physician has ordered injections of Neumega (oprelvekin) for a client receiving chemotherapy for prostate cancer. Which finding suggests that the medication is having its desired effect?
(a) Hct 12.8g 
(b) Platelets 250,000mm³ 
(c) Neutrophils 4,000mm³ 
(d) RBC 4.7 million
Answer:
(b) Platelets 250,000mm³ 

Rationale:
Neumega stimulates the production of platelets, so a finding of 250,000mm3 suggests that the medication is working. Answers (a) and (d) are associated with the use of Epogen, and answer (c) is associated with the use of Neupogen; therefore, they are incorrect.

Question 197.    
A child suspected of having cystic fibrosis is scheduled for a quantitative sweat test. The nurse knows that the quantitative sweat test will be analyzed using:
(a) Pilocarpine iontophoresis 
(b) Choloride iontophoresis 
(c) Sodium iontophoresis 
(d) Potassium iontophoresis
Answer:
(a) Pilocarpine iontophoresis 

Rationale:
Pilocarpine, a substance that stimulates sweating, is used to diagnose cystic fibrosis. Chloride and sodium levels in the sweat are measured by the test, but they do not stimulate sweating; therefore, answers (b) and (c) are incorrect. Answer (d) is incorrect because it is not associated with cystic fibrosis.

Question 198.    
The nurse is caring for a client with a Brown-Sequard spinal cord injury. The nurse should expect the client to have:
(a) Total loss of motor, sensory, and reflex activity 
(b) Incomplete loss of motor function 
(c) Loss of sensory function with potential for recovery
(d) Loss of sensation on the side opposite the injury
Answer:
(d) Loss of sensation on the side opposite the injury

Rationale:
The client with a Brown Sequard spinal cord injury will have a loss of sensation on the side opposite the cord injury. Answer (a) is incorrect because it describes a complete cord lesion. Answer (b) is incorrect because it describes central cord syndrome. Answer (c) is incorrect because it describes cauda equina syndromes.

Question 199.    
A client with cirrhosis has developed signs of heptorenal syndrome. Which diet is most appropriate for the client at this time?
(a) High protein, moderate sodium 
(b) High carbohydrate, moderate sodium 
(c) Low protein, low sodium
(d) Low carbohydrate, high protein
Answer:
(c) Low protein, low sodium

Rationale:
The client with signs of heptorenal syndrome should have a diet that is low in protein and sodium, to decrease serum ammonia levels. Answer (a) is incorrect because the client will not benefit from a high-protein diet and sodium will be restricted. A high-carbohydrate diet will provide the client with calories; however, sodium intake is restricted, making answer (b) incorrect. Answer (d) is incorrect because the client will not benefit from a high-protein diet, which would increase ammonia levels.

Question 200.    
The nurse is caring for a client with a basal cell epithelioma. The primary cause of basal cell epithelioma is:
(a) Sun exposure
(b) Smoking
(c) Ingestion of alcohol
(d) Food preservatives
Answer:
(a) Sun exposure

Rationale:
Basal cell epithelioma, or skin cancer, is related to sun exposure. Answers (b), (c), and (d) are incorrect because they are not associated with the development of basal cell epithelioma.

Question 201.
A client with in situ bladder cancer is receiving intravesical therapy using BCG. During treatment the nurse should do which of the follow:
(a) Ask the client to remain still after the medication is instilled.
(b) Offer the client additional oral fluids.
(c) Ask the client to change positions every fifteen minutes.
(d) Ask the client to void every hour.
Answer:
(c) Ask the client to change positions every fifteen minutes.

Rationale:
The nurse should tell the client to change positions every fifteen minutes to provide maximum contact of the BCG with all areas of the bladder. Answer (a) is incorrect because the client does not need to remain still. Answer (b) is incorrect because oral fluids should be encouraged after the treatment time is completed.
Answer (d) is incorrect because the client needs to void before the BCG is instilled, not during treatment time.

Question 202.
A client is event of a receiving a blood transfusion following surgery. In the transfusion reaction, any unused blood should be:
(a) Sealed and discarded in a red bag
(b) Flushed down the client’s commode
(c) Sealed and discarded in the sharp’s container
(d) Returned to the blood bank
Answer:
(d) Returned to the blood bank

Rationale:
Any unused blood should be returned to the blood bank. Answers (a), (b), and (c) are incorrect because they are improper ways of handling the unused blood.

Question 203.
The physician has ordered a trivalent botulism antitoxin for a client with botulism poisoning. Before administering the medication, the nurse should assess the client for a history of allergies to:
(a) Eggs
(b) Horses
(c) Shellfish
(d) Pork
Answer:
(b) Horses

Rationale:
Trivalent botulism antitoxin is made from horse serum; therefore, the nurse needs to assess the client for allergies to horses. Answers (a), (c), and (d) are incorrect because they are not involved in the manufacturing of trivalent botulism antitoxin.

Question 204.    
The physician has ordered increased oral hydration for a client with renal calculi. Unless contraindicated, the recommended oral intake for helping with the removal of renal calculi is:
(a) 75mL per hour
(b) 100mL per hour
(c) 150mL per hour
(d) 200mL per hour
Answer:
(d) 200mL per hour

Rationale:
Unless contraindicated, the client with renal calculi should receive 200mL of fluid per hour to help flush the calculi from the kidneys. Answers (a), (b), and (c) are incorrect choices because the amounts are inadequate.

Question 205.    
The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client’s mouth using:
(a) A toothbrush 
(b) A soft gauze pad 
(c) Antiseptic mouthwash 
(d) Lemon and glycerin swabs
Answer:
(b) A soft gauze pad 

Rationale:
A soft gauze pad should be used to clean the oral mucosa of a client with oral candidiasis. Answer (a) is incorrect because it is too abrasive to the mucosa of a client with oral candidiasis. Answer (c) is incorrect because the mouthwash contains alcohol, which can burn the client’s mouth. Answer (d) is incorrect because lemon and glycerin will cause burning and drying of the client’s oral mucosa.
 
Question 206.    
A client taking anticoagulant medication has developed a cardiac tamponade. Which finding is associated with cardiac tamponade?
(a) A decrease in systolic blood pressure during inspiration
(b) An increase in diastolic blood pressure during expiration
(c) An increase in systolic blood pressure during inspiration
(d) A decrease in diastolic blood pressure during expiration
Answer:
(a) A decrease in systolic blood pressure during inspiration

Rationale:
The client with a cardiac tamponade will exhibit a decrease of 10mmHg or greater in systolic blood pressure during inspirations. This phenomenon, known as pulsus paradoxus, is related to blood pooling in the pulmonary veins during inspiration. Answers (b), (c), and (d) are incorrect because they contain inaccurate statements.

Question 207.    
The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
(a) Take aspirin for discomfort
(b) Avoid bending over to put on his shoes
(c) Remove the eye shield before going to sleep
(d) Continue showering as usual
Answer:
(b) Avoid bending over to put on his shoes

Rationale:
Following removal of a cataract, the client should avoid bending over for several days because this increases intraocular pressure. The client should avoid aspirin because it increases the likelihood of bleeding, and the client should keep the eye shield on when sleeping, so answers (a) and (c) are incorrect. Answer (d) is incorrect because the client should not face into the shower stream after having cataract removal because this can cause trauma to the operative eye.

Question 208.    
The physician has ordered Pentam (pentamidine) IV for a client with pneumocystis carinii. While receiving the medication, the nurse should carefully monitor the client’s:
(a) Blood pressure
(b) Temperature
(c) Heart rate
(d) Respirations
Answer:
(a) Blood pressure

Rationale:
A severe toxic side effect of pentamidine is hypotension. Answers (b), (c), and (d) are not related to the administration of pentamidine; therefore, they are incorrect.

Question 209.    
Intra-arterial chemotherapy primarily benefits the client by applying greater concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is:
(a) Prevention of nausea and vomiting
(b) Treatment of micro-metastasis
(c) Eradication of bone pain
(d) Prevention of therapy-induced anemia
Answer:
(b) Treatment of micro-metastasis

Rationale:
A secondary benefit of intra-arterial chemotherapy is that it helps in the treatment of micrometastasis from cancerous tumors. Intra-arterial chemothera¬py lessens systemic effects but does not prevent or eradicate them; therefore, answers (a), (c), and (d) are incorrect.

Question 210.    
A client with rheumatoid arthritis is receiving injections of Myochrysine (gold sodium thiomalate). Before administering the client’s medication, the nurse should:
(a) Check the lab work.
(b) Administer an antiemetic.
(c) Obtain the blood pressure.
(d) Administer a sedative
Answer:
(a) Check the lab work.

Rationale:
Before administering gold salts, the nurse should check the lab work for the complete blood count and urine protein level because gold salts are toxic to the kidneys and the bone marrow. Answer (b) is incorrect because it is not necessary to give an antiemetic before administering the medication. Changes in vital signs are not associated with the medication, and a sedative is not needed before receiving the medication; therefore, answers (c) and (d) are incorrect.

Question 211.    
The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:
(a) Document the finding and continue to monitor the client.
(b) Irrigate the drainage tube with 10mL of normal saline. 
(c) Decrease the amount of intermittent suction.
(d) Notify the physician of the findings.
Answer:
(d) Notify the physician of the findings.

Rationale:
The appearance of increased drainage that is clear, colorless, or bile tinged indicates disruption or leakage at one of the anastamosis sites, requiring the immediate attention of the physician. Answer (a) is incorrect because the client’s condition will worsen without prompt intervention. Answers (b) and (c) are incorrect choices because they cannot be performed without a physician’s order.

Question 212.    
A client with AIDS tells the nurse that he regularly takes echinacea to boost his immune system. The nurse should tell the client that:
(a) Herbals can interfere with the action of antiviral medication.
(b) Supplements have proven effective in prolonging life. 
(c) Herbals have been shown to decrease the viral load.
(d) Supplements appear to prevent replication of the virus.
Answer:
(a) Herbals can interfere with the action of antiviral medication.

Rationale:
Herbals such as echinacea can interfere with the action of antiviral medications; therefore, the client should discuss the use of herbals with his physician. Answer (b) is incorrect because supplements have not been shown to prolong life. Answer (c) is incorrect because herbals have not been shown to be effective in decreasing the viral load. Answer (d) is incorrect because supplements do not prevent replication of the virus.

Question 213.    
A client with rheumatoid arthritis has Sjogren’s syndrome. The nurse can help relieve the symptoms of Sjogren’s syndrome by:
(a) Providing heat to the joints
(b) Instilling eyedrops
(c) Administering pain medication
(d) Providing small, frequent meals
Answer:
(b) Instilling eyedrops

Rationale:
The client with Sjogren’s syndrome complains of dryness of the eyes. The nurse can help relieve the client's symptoms by instilling artificial tears. Answers (a), (c), and (d) do not relieve the symptoms of Sjogren’s syndrome; therefore, they are incorrect.

Question 214.    
Which one of the following symptoms is common in the client with duodenal ulcers?
(a) Vomiting shortly after eating
(b) Epigastric pain following meals
(c) Frequent bouts of diarrhea
(d) Presence of blood in the stools
Answer:
(d) Presence of blood in the stools

Rationale:
Melena, or blood in the stool, is common in the client with duodenal ulcers. Answers (a) and (b) are symptoms of gastric ulcers, and diarrhea is not a symptom of duodenal ulcers; therefore, answers (a), (b), and (c) are incorrect.

Question 215.    
A client with end-stage renal failure receives hemodialysis via an arteriovenous fistula (AV) placed in the right arm. When caring for the client, the nurse should:
(a) Take the blood pressure in the right arm above the AV fistula.
(b) Flush the AV fistula with IV normal saline to keep it patent.
(c) Auscultate the AV fistula for the presence of a    bruit.
(d) Perform needed venopunctures    distal to the AV fistula. 
Answer:
(c) Auscultate the AV fistula for the presence of a    bruit.

Rationale:
The nurse should auscultate the fistula for the presence of a bruit, which indicates that the fistula is patent. Answer (a) is incorrect because repeated compressions such as obtaining the blood pressure can result in damage to the AV fistula. Answer (b) is incorrect because the AV fistula is not used for the administration of IV fluids. Answer (d) is incorrect because venopunctures are not done in the arm with an AV fistula.

Question 216.    
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
(a) A client with chronic renal failure with a serum creatinine of 5.6mg/dL
(b) A client with rheumatic fever with a positive C reactive protein
(c) A client with gastroenteritis with a hematocrit of 52%
(d) A client with epilepsy with a white cell count of 3,800mm³
Answer:
(d) A client with epilepsy with a white cell count of 3,800mm³

Rationale:
A client with epilepsy is managed with anticonvulsant medication. An adverse side effect of anticonvulsant medication is decreased white cell count. Answer (a) is incorrect because elevations in serum creatinine are expected in the client with chronic renal failure. Answer (b) is incorrect because a positive C reactive protein is expected in the client with rheumatic fever. Elevations in hematocrit are expected in a client with gastroenteritis because of dehydration; therefore, answer (c) is incorrect.

Question 217.
The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:
(a) Increased weight
(b) A sore throat
(c) Difficulty in sleeping
(d) Changes in mood
Answer:
(b) A sore throat

Rationale:
Clients who use steroid medications, such as beclomethasone, can develop adverse side effects, including oral infections with Candida albicans. Symptoms of Candida albicans include sore throat and white patches on the oral mucosa. Increased weight, difficulty sleeping, and changes in mood are expected side effects; therefore, answers (a), (c), and (d) are incorrect.

Question 218.    
A client treated for depression has developed symptoms of sero-tonin syndrome. The nurse recognizes that serotonin syndrome might result when the client takes both a prescribed antidepres-sant and which of the following?
(a) St. John’s wort
(b) Ginko biloba
(c) Black cohosh
(d) Saw palmetto
Answer:
(a) St. John’s wort

Rationale:
Symptoms of serotonin syndrome can result when the client takes both a prescribed antidepressant and St. John’s wort. The use of ginko biloba, black cohosh, and saw palmetto with prescribed antidepressants is not associated with an increased risk of serotoin syndrome; therefore, answers (b), (c), and (d) are incorrect.

Question 219.    
The nurse is caring for a client following a transphenoidal hypophysectomy. Post-operatively, the nurse should:
(a) Provide the client a toothbrush for mouth care.
(b) Check the nasal dressing for the “halo sign.”
(c) Tell the client to cough forcibly every two hours.
(d) Ambulate the client when he is fully awake.
Answer:
(b) Check the nasal dressing for the “halo sign.”

Rationale:
The nurse should check the nasal packing for the presence of the “halo sign,” or a light yellow color at the edge of clear drainage on the nasal dressing. The presence of the halo sign indicates leakage of cerebral spinal fluid. Answer (a) is incorrect because the nurse provides mouth care using oral washes not a toothbrush. Answer (c) is incorrect because coughing increases pressure in the incisional area and can lead to a cerebral spinal fluid leak. Answer (d) is incorrect because the client should not be ambulated for 1-3 days after surgery.

Question 220.    
The physician has inserted an esophageal balloon tamponade in a client with bleeding esophageal varices. The nurse should main-tain the esophageal balloon at a pressure of:
(a) 5-10mmHg 
(b) 10-15mmHg 
(c) 15-20mmHg 
(d) 20-25mmHg 
Answer:
(d) 20-25mmHg 

Rationale:
The esophageal balloon tamponade should be maintained at a pressure of 20-25mmHg to help decrease bleeding from the esophageal varices. Answers (a), (b), and (c) are incorrect because the pressures are too low to be effective.

Question 221.    
The nurse is caring for a client with Lyme’s disease. The nurse should carefully monitor the client for signs of neurological com-plications, which include:
(a) Complaints of a “drawing” sensation and paralysis on one side of the face
(b) Presence of an unsteady gait, intention tremor, and facial weakness
(c) Complaints of excruciating facial pain brought on by talking, smiling, or eating
(d) Presence of fatigue when talking, dysphagia, and involuntary facial twitching
Answer:
(a) Complaints of a “drawing” sensation and paralysis on one side of the face

Rationale:
The most common neurological complication of Lyme’s disease is Bell’s palsy. Symptoms of Bell’s palsy include complaints of a “drawing” sensation and paralysis on one side of the face. Answer (b) is incorrect because it describes symptoms of multiple sclerosis. Answer (c) is incorrect because it describes symptoms of trigeminal neuralgia. Answer (d) is incorrect because it describes symptoms of amyotrophic lateral sclerosis. Multiple sclerosis, trigeminal neuralgia, and amyotrophic lateral sclerosis are not associated with Lyme’s disease.

Question 222.    
When caring for the child with autistic disorder, the nurse should:
(a) Take the child to the playroom to be with peers.
(b) Assign a consistent caregiver.
(c) Place the child in a ward with other children.
(d) Assign several staff members to provide care.
Answer:
(b) Assign a consistent caregiver.

Rationale:
The child with autistic disorder is easily upset by changes in routine; therefore, the nurse should assign a consistent caregiver. Answers (a), (c), and (d) are incorrect because they provide too much stimulation and change in routine for the child with autistic disorder.

Question 223.    
A client is admitted with suspected pernicious anemia. Which find-ings support the diagnosis of pernicious anemia?
(a) The client complains of feeling tired and listless.
(b) The client has waxy, pale skin.
(c) The client exhibits loss of coordination and position sense.
(d) The client has a rapid pulse rate and a detectable heart murmur.
Answer:
(c) The client exhibits loss of coordination and position sense.

Rationale:
Pernicious anemia is characterized by changes in neurological function such as loss of coordination and loss of position sense. Answers (a), (b), and (d) are applicable to all types of anemia; therefore, they are incorrect.

Question 224.    
The physician has prescribed Cyclogel (cyclopentolate hydrochlo-ride) drops for a client following a scleral buckling. The nurse knows that the purpose of the medication is to:
(a) Rest the muscles of accommodation 
(b) Prevent post-operative infection
(c) Constrict the pupils
(d) Reduce the production of aqueous humor
Answer:
(a) Rest the muscles of accommodation 

Rationale:
Cyclogel is a cycloplegic medication that inhibits constriction of the pupil and rests the muscles of accommodation. Answer (b) is incorrect because the medication does not prevent post-operative infection. Answer (c) is incorrect because the medication keeps the pupil from constricting. Answer (d) is incorrect because it does not decrease the production of aqueous humor.

Question 225.    
Which finding is associated with secondary syphilis?
(a) Painless, papular lesions on the perineum, fingers, and eyelids
(b) Absence of lesions
(c) Deep asymmetrical granulomatous    lesions
(d) Well-defined generalized lesions on the palms, soles, and perineum 
Answer:
(d) Well-defined generalized lesions on the palms, soles, and perineum 

Rationale:
Secondary syphilis is characterized by well-defined generalized lesions on the palms, soles, and perineum. Lesions can enlarge and erode, leaving highly contagious pink or grayish-white lesions. Answer (a) describes the chancre associated with primary syphilis, answer (b) describes the latent stage of syphilis, and answer (c) describes late syphilis.

Question 226.
A client is transferred to the intensive care unit following a coronary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
(a) Urine output of 50ml in the past hour
(b) Temperature of 99°F
(c) Strong pedal pulses bilaterally
(d) Central venous pressure 15mmH₂O
Answer:
(d) Central venous pressure 15mmH₂O

Rationale:
The central venous pressure of 15mm H2O indicates fluid overload. Answers (a), (b), and (c) are incorrect because they are not a cause for concern; therefore, they do not need to be reported to the physician.

Question 227.
Which symptom is not associated with glaucoma?
(a) Veil-like loss of vision
(b) Foggy loss of vision
(c) Seeing halos around lights
(d) Complaints of eye pain
Answer:
(a) Veil-like loss of vision

Rationale:
Veil-like loss of vision is a symptom of a detached retina, not glaucoma. Answers (b), (c), and (d) are symptoms associated with glaucoma; therefore, they are incorrect.

Question 228. 
When caring for a ventilator-dependent client who is receiving tube feedings, the nurse can help prevent aspiration of gastric secretions by:
(a) Keeping the head of the bed flat
(b) Elevating the head of the bed 30-45°
(c) Placing the client on his left side
(d) Raising the foot of the bed 10-20°
Answer:
(b) Elevating the head of the bed 30-45°

Rationale:
According to the Centers for Disease Control (CDC), the ventilator-dependent client who is receiving tube feedings should have the head of the bed elevated 30-45° to prevent aspiration of gastric secretions. Keeping the head of the bed flat has been shown to increase aspiration of gastric secretions; therefore, answer (a) is incorrect. Answer (c) is incorrect because placing the client on his left side has not been shown to decrease the incidence of aspiration of gastric secretions. Answer (d) is incorrect because it would increase the incidence of aspiration of gastric secretions.

Question 229.
When gathering evidence from a victim of rape, the nurse should place the victim’s clothing in a:
(a) Plastic zip-lock bag
(b) Rubber tote
(c) Paper bag
(d) Padded manila envelope
Answer:
(c) Paper bag

Rationale:
A paper bag should be used for the victim’s clothing because it will allow the clothes to dry without destroying evidence. Answers (a) and (b) are incorrect because plastic and rubber retain moisture that can deteriorate evidence. Answer (d) is incorrect because padded envelopes are plastic lined, and plastic retains moisture that can deteriorate evidence.

Question 230.    
The nurse on an orthopedic unit is assigned to care for four clients with displaced bone fractures. Which client will not be treated with the use of traction?
(a) A client with fractures of the femur
(b) A client with fractures of the cervical spine
(c) A client with fractures of the humerus
(d) A client with fractures of the ankle 
Answer:
(d) A client with fractures of the ankle 

Rationale:
Because of the anatomic location, fractures of the ankle are not treated with traction. Answers (a), (b), and (c) are incorrect because they are treated by the use of traction.

Question 231.    
A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?
(a) Decreased cardiac output related to damage to the myocardium
(b) Impaired tissue perfusion related to an occlusion in the coronary vessels
(c) Acute pain related to cardiac ischemia
(d) Ineffective breathing patterns related to decreased oxygen to the tissues
Answer:
(b) Impaired tissue perfusion related to an occlusion in the coronary vessels

Rationale:
The cause of acute myocardial infarction is occlusion in the coronary vessels by a clot or atherosclerotic plaque. Answers (a) and (c) are incorrect because they are the result, not the cause, of acute myocardial infarction. Answer (d) is incorrect because it reflects a compensatory action in which the depth and rate of respirations changes to compensate for decreased cardiac output.

Question 232.    
The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
(a) A 23-year-old female complaining of headache and nausea
(b) A 76-year-old male complaining of dysuria
(c) A 56-year-old male complaining of exertional shortness of breath
(d) A 42-year-old female complaining of recent sexual assault
Answer:
(d) A 42-year-old female complaining of recent sexual assault

Rationale:
The client complaining of sexual assault should be taken immediately to a private area rather than left sitting in the waiting room. Answers (a), (b), and (c) require intervention, but the clients can remain in the waiting room.

Question 233.    
The physician has ordered an injection of morphine for a client with post-operative pain. Before administering the medication, it is essential that the nurse assess the client’s:
(a) Heart rate
(b) Respirations
(c) Temperature
(d) Blood pressure
Answer:
(b) Respirations

Rationale:
Morphine is an opiate that can severely depress the client’s res¬pirations. The word essential implies that this vital sign must be assessed to provide for the client’s safety. Answers (a), (c), and (d) are incorrect choices because they are not necessarily associated before administering morphine.

Question 234.    
The nurse is caring for a client with a closed head injury. A late sign of increased intracranial pressure is:
(a) Changes in pupil equality and reactivity 
(b) Restlessness and irritability 
(c) Complaints of headache 
(d) Nausea and vomiting 
Answer:
(a) Changes in pupil equality and reactivity 

Rationale:
Changes in pupil equality and reactivity, including sluggish pupil reaction, are late signs of increased intracranial pressure. Answers (b), (c), and (d) are incorrect because they are early signs of increased intracranial pressure.

Question 235.    
The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurse’s best response at this time is to:
(a) Attempt to perform the procedure.
(b) Refuse to perform the procedure and give a reason for the refusal.
(c) Request to observe a similar procedure and then attempt to complete the procedure.
(d) Agree to perform the procedure if the client is willing.
Answer:
(b) Refuse to perform the procedure and give a reason for the refusal.

Rationale:
If the newly licensed nurse thinks he is unqualified to perform a procedure at this time, he should refuse, give a reason for the refusal, and request training. Answers (a), (c), and (d) can result in injury to the client and bring legal charges against the nurse; therefore, they are incorrect choices.

Question 236.    
A client is admitted to the emergency department with complaints of crushing chest pain that radiates to the left jaw. After obtaining a stat electrocardiogram the nurse should:
(a) Obtain a history of prior cardiac problems
(b) Begin an IV using a large-bore catheter
(c) Administer oxygen at 2L per minute via nasal cannula
(d) Perform pupil checks for size and reaction to light
Answer:
(c) Administer oxygen at 2L per minute via nasal cannula

Rationale:
The nurse should give priority to administering oxygen via nasal cannula. Answer (a) is incorrect because the history of prior cardiac problems can be obtained after the client’s condition has stabilized. Answer (b) is incorrect because starting an IV is done after the client’s oxygen needs are met. Answer (d) is incorrect because pupil checks are part of a neurological assessment, which is not indicated for the situation.

Question 237.    
Which of the following techniques is recommended for removing a tick from the skin?
(a) Grasping the tick with a tissue and quickly jerking it away from the skin
(b) Placing a burning match close the tick and watching for it to release
(c) Using tweezers, grasp the tick close to the skin and pull the tick free using a steady, firm motion
(d) Covering the tick with petroleum jelly and gently rubbing the area until the tick releases
Answer:
(c) Using tweezers, grasp the tick close to the skin and pull the tick free using a steady, firm motion

Rationale:
The recommended way of removing a tick is to use tweezers. The tick is grasped close to the skin and removed using a steady, firm motion. Quickly jerking the tick away from the skin, placing a burning match close to the tick, and covering the tick with petroleum jelly increases the likelihood that the tick will regurgitate contaminated saliva into the wound therefore answers (a), (b), and (d) are incorrect.

Question 238.    
A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player’s nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to:
(a) Tilt the head back and pinch the nostrils.
(b) Apply a wrapped ice compress to the nose.
(c) Pack the nose with soft, clean tissue.
(d) Tilt the head forward and pinch the nostrils. 
Answer:
(b) Apply a wrapped ice compress to the nose.

Rationale:
The application of a wrapped ice compress will help decrease bleeding by causing vasoconstriction. Answer (a) is incorrect because the client’s head should be tilted forward, not back. Nothing should be placed inside the nose except by the physician; therefore, answer (c) is incorrect. Answer (d) is incorrect because the nostrils should not be pinched due to a visible deformity.

Question 239.    
What is the responsibility of the nurse in obtaining an informed consent for surgery?
(a) Describing in a clear and simply stated manner what the surgery will involve
(b) Explaining the benefits, alternatives, and possible risks and complications of surgery
(c) Using the nurse/client relationship to persuade the client to sign the operative permit
(d) Providing the informed consent for surgery and witnessing the client’s signature
Answer:
(d) Providing the informed consent for surgery and witnessing the client’s signature

Rationale:
The nurse’s responsibility in obtaining an informed consent for surgery is providing the client with the consent form and witnessing the client’s signature. Answers (a) and (b) are the responsibility of the physician, not the nurse. Answer (c) is incorrect because the nurse-client relationship should never be used to persuade the client to sign a permit for surgery or other medical treatments.

Question 240.    
During the change of shift report, the nurse states that the client’s last pulse strength was a 1+. The oncoming nurse recognizes that the client’s pulse was:
(a) Bounding 
(b) Full 
(c) Normal 
(d) Weak
Answer:
(d) Weak

Rationale:
A pulse strength of 1⁺ is a weak pulse. Answer (a) is incorrect because it refers to a pulse strength of 4⁺. Answer (b) is incorrect because it refers to a pulse strength of 3⁺. Answer (c) is incorrect because it refers to a pulse strength of 2⁺.

Question 241.
The RN is making assignments for the day. Which one of the fol-lowing duties can be assigned to the unlicensed assistive person-nel?
(a) Notifying the physician of an abnormal lab value 
(b) Providing routine catheter care with soap and water 
(c) Administering two aspirin to a client with a headache 
(d) Setting the rate of an infusion of normal saline
Answer:
(b) Providing routine catheter care with soap and water 

Rationale:
Unlicensed assistive personnel can perform routine catheter care with soap and water. Answers (a), (c), and (d) are incorrect because they are actions that must be performed by the licensed nurse.

Question 242.    
The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to one minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
(a) Cheyne-Stokes respirations
(b) Kussmaul respirations
(c) Biot respirations
(d) Diaphragmatic respirations 
Answer:
(a) Cheyne-Stokes respirations

Rationale:
The client’s respiratory pattern is that of Cheyne-Stokes respirations. Answer (b) is incorrect because Kussmaul respirations, associated with diabetic ketoacidosis, are characterized by an increase in the rate and depth of respirations. Answer (c) is incorrect because Biot respirations are characterized by several short respirations followed by long, irregular periods of apnea. Answer (d) is incorrect because diaphragmatic respirations refer to abdominal breathing.

Question 243.    
A client seen in the doctor’s office for complaints of nausea and vomiting is sent home with directions to follow a clear-liquid diet for the next 24-48 hours. Which of the following is not permitted on a clear-liquid diet?
(a) Sweetened tea
(b) Chicken broth
(c) Ice cream
(d) Orange gelatin
Answer:
(c) Ice cream

Rationale:
Milk and milk products are not permitted on a clear-liquid diet. Answers (a), (b), and (d) are permitted on a clear-liquid diet; therefore, they are incorrect.

Question 244.    
When administering a tuberculin skin test, the nurse should insert the needle at a:
(a) 15° angle
(b) 30° angle
(c) 45° angle
(d) 90° angle
Answer:
(a) 15° angle

Rationale:
The tuberculin skin test is given by intradermal injection. Intradermal injections are administered by inserting the needle at a 5-15° angle. Answers (b), (c), and (d) are incorrect because the angle is not used for intradermal injections.

Question 245.    
The nurse is preparing to discharge a client following a trabeculo-plasty for the treatment of glaucoma. The nurse should instruct the client to:
(a) Wash her eyes with baby shampoo and water twice a day
(b) Take only tub baths for the first month following surgery
(c) Begin using her eye makeup again one week after surgery
(d) Wear eye protection for several months after surgery
Answer:
(d) Wear eye protection for several months after surgery

Rationale:
Following a trabeculoplasty, the client is instructed to wear eye protection continuously for several months. Eye protection can be in the form of pro¬tective glasses or an eye shield that is worn during sleep. Answer (a) is not correct because the client is instructed to keep soap and water away from the eyes. Answer (b) is incorrect because showering is permitted as long as soap and water are kept away from the eyes. Answer (c) is incorrect because the client should avoid using eye make up for at least a month after surgery.

Question 246.    
Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator- associated pneumonia?
(a) Uncuffed
(b) CASS
(c) Fenestrated
(d) Nasotracheal
Answer:
(b) CASS

Rationale:
The CASS (continuous aspiration of subglottic secretions) tube features an evacuation port above the cuff, making it possible to remove secretions above the cuff. Use of an uncuffed tube increases the incidence of ventilator pneumonia by allowing aspiration of secretions, making answer (a) incorrect. Answer (c) is incorrect because the fenestrated tube has openings that increase the risk of pneumonia. Answer (d) is incorrect because nasotracheal refers to one of the routes for inserting an endotracheal tube, not a type of tube.

Question 247.    
Which client is at greatest risk for complications following abdominal surgery?
(a) A 68-year-old obese client with non-insulin-dependent diabetes
(b) A 27-year-old client with a recent history of urinary tract infections
(c) A 16-year-old client who smokes a half-pack of cigarettes per day
(d) A 40-year-old client who exercises regularly, with no history of medical conditions
Answer:
(a) A 68-year-old obese client with non-insulin-dependent diabetes

Rationale:
This client has multiple risk factors for complications following abdominal surgery, including age, weight, and an endocrine disorder. Answer (b) is incorrect because the client has only one significant factor, the recent urinary tract infection. Answer (c) is incorrect because the client has only one significant factor, the use of tobacco. Answer (d) is incorrect because the client has no significant factors for post-operative complications.

Question 248.    
The nurse is preparing a client for surgery. Which lab finding should be reported to the physician?
(a) Potassium 2.5mEq/L 
(b) Hemoglobin 14.5g/dL 
(c) Blood glucose 75mg/dL 
(d) White cell count 8,000mm³
Answer:
(a) Potassium 2.5mEq/L 

Rationale:
The client’s potassium level is low. The normal potassium level is 3.5-5.5mEq/L. Answers (b), (c), and (d) are within normal range and, therefore, are incorrect.

Question 249.    
A client is diagnosed with bleeding from the upper gastrointestinal system. The nurse would expect the client’s stools to be:
(a) Brown 
(b) Black 
(c) Clay colored 
(d) Green
Answer:
(b) Black 

Rationale:
Black or tarry stools are associated with upper gastrointestinal bleeding. Normal stools are brown in color, clay-colored stools are associated with biliary obstruction, and green stools are associated with infection or large amounts of bile; therefore, answers (a), (c), and (d) are incorrect.

Question 250.    
The physician has prescribed Chloromycetin (chloramphenicol) for a client with bacterial meningitis. Which lab report should the nurse monitor most carefully?
(a) Serum creatinine
(b) Urine specific gravity
(c) Complete blood count
(d) Serum sodium
Answer:
(c) Complete blood count

Rationale:
An adverse side effect of chloramphenicol is aplastic anemia; therefore, the nurse should pay particular attention to the client’s complete blood count. Answers (a), (b), and (d) should be noted, but they are not directly affected by the medication and are incorrect.